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ECLECTIC    TREATISE 


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PEACTICE  OE  MEDICINiL 


EMBRACING 


THE  PATHOLOGY  OF  INFLAMMATION  AND  FEVER, 


CLASSIFICATION  AND   TBEATHSNT. 


BY 


EOBEET  S.  MwTON,  M.D., 

PROFESSOR    OP   CLINIC    MEDICINE   AND    SURGERY   IN   THE     ECLECTIC    MEDICAL   INSTITUTK 
OF   CINCINNATI,   OHIO- 


CINCINNATI; 
1861. 


•v^" 


TO  THE  READER. 

In  conclusion,  it  is  proper  to  remark,  that  when  we  began 
this  work,  it  was  our  intention  to  make  a  complete  work  on 
Practice.  Having  concluded  to  go  no  farther  for  the  present, 
this  portion  is  submitted  to  the  reader,  believing  that  the  true 
pathology  has  been  laid  down,  and  if  made  the  basis  of  prac- 
tice, it  will,  in  every  case,  demonstrate  fully  the  truth  of  the 
doctrine  taught  in  the  preceding  pages. 

Twenty  years'  practice  has  given  us  a  fair  opportunity  to 
judge  of  the  various  plans  of  medication  based  upon  the  sev- 
eral theories  of  pathology,  and  after  trying,  ftiUy  and  fairly, 
the  Allopathic  and  Eclectic  modes  and  results,  we  are  forced 
to  say,  that  at  least  fifty  per  cent,  of  cases  are  in  favor  of  the 
latter. 


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C02^Ta?B3S^TS. 


PAGE 

BiliousFever, 104 

Change  of  type  in  fever, 142 

Classification  of  the  various  forms  of  disease, 57 

Congestive  fever, 112 

Febrile  forms  of  disease,  in  general: 58 

Fever,  continued  and  periodic, 63 

Febris,  vasorum, 73 

Fever,  synochus — continued  synochus — enteric  —  typhoid  miteor — typhoid 

entero — misenteric, 76 

Fever,  typhous  —  typhous  gravior  —  spotted — petecchial  —  putrid — camp — 

ship— jail — hospital 128,  87 

Fever,  intermittent, 93 

Fever,  remittent — ^bilious — bilous  remittent, 104 

Fever,  congestive — pernicious — pernicious  remittent— pernicious  intermittent,  112 
Fever,  infantile  remittent  —  acute  infantile  remittent — slow  infantile  remit- 

'     tent — low  infantile  remittent, 124 

lufiammation  and  fever, 9 

Is  the  type  of  disease  the  same  as  it  was  twenty-five  years  ago? 9 

Inflammation, 46 

Inflammatory  fever, 73 

Intermittent  fever 93 

Pathology  of  inflammation  and  fever, 9 

Pathological  condition  under  circumstances, 9 

Pyrexia, 58 

Periodic  and  continued  fever 64 

Pyrexia  sthenica,.' 73 

Pernicious  fever, 112 

Remittent  fever, 104 

Synochal  grade  of  idiopathic  fever, 73 

Stimulants  in  continued  fever, 137 

Typhus  fever, 117 

Typhoid  and  typhous  fevers, 128 

Yellow  fever, 117 


AN  ECLECTIC   TREATISE 


PRACTICE  OF  MEDICINE. 


CHAPTER    I. 


The  Pathology  of  Inflammation  and  Fever — Fevek  and 
Inflammation — a  Pathological  Condition  under  Circum- 
stances—  Thk  Discussion  of  Drs.  Bennet  and  AiisoN, 
Of  Edinburgh,  upon  the  Change  of  Types  of  Disease — Is 
the  Type  of  Disease  the  same  as  it  was  Twenty-Fivb 
Years  Ago? 

There  are  two  states  of  the  human  body — a  state  of  health 
and  a  state  of  disease.  The  former  is  maintained  by  a  due 
equilibrium  between  the  various  normal  functions  of  the  human 
organism ;  and  the  study  of  that  equilibrium  constitutes  the 
science  of  physiology.  The  latter  is  the  result  of  a  departure 
from  the  physiological  equilibrium,  and  the  study  of  those 
departures  constitutes  the  science  of  pathology.  The  former 
study  is  essentially  necessary  to  enable  the  practitioner  to  per- 
ceive and  comprehend  those  pathological  states  whose  mani- 
festations constitute  disease.  There  are  some  general  physi- 
ological laws,  which  it  is  believed  every  medical  man  either 
does  or  ought  to  comprehend ;  or,  when  he  undertook  the  care 
of  a  case,  he  would  be  very  much  in  the  condition  of  a  blind 
optician,  or  a  deaf  newspaper  reporter.  So,  too,  there  are 
some  general  principles  of  pathology,  which  ought  to  be  fully 
comprehended  by  every  practitioner. 

I  have  set  out  to  write  an  eclectic  treatise  on  the  practice  of 
medicine,  and  this  I  mean  to  perform  with  reference  to  the 
requirements  of  those  who  are  actually  engaged  in  the  exercises 
1 


10  ECLECTIC   TEEATI8E   ON  THE 

of  the  healing  art.  I  shall  endeavor  to  produce  a  series  of  pages 
worthy  of  confidence,  and  one  which  shall  contain  such  informa- 
tion, and  such  only,  as  will  be  of  service  to  the  practitioner. 
There  is  no  such  book  in  existence ;  those  that  we  have  being  too 
exclusively  theoretical,  or  otherwise  greatly  deficient.  During 
the  past  sixteen  years,  I  have  been  in  the  daily  practice  of 
medicine  and  surgery,  and  for  the  last  ten  as  a  lecturer  on  the 
practice  of  medicine  and  the  principles  and  practice  of  surgery, 
and  my  own  experience  of  what  kind  of  a  work  is  needed  will 
direct  me  in  the  preparation  of  this. 

The  science  of  medicine,  though  of  great  antiquity,  is  still 
rery  imperfect.  When  physiology,  pathology,  anatomy,  etc., 
had  hardly  yet  begun  to  claim  special  attention,  of  couree  the 
practice  was  little  better  than  mere  guess-work ;  but  as  phy- 
sicians came  to  the  study  of  the  special  departments,  as  truth 
after  truth  was  unfolded,  so  the  old  errors  were  cast  ofi*  and 
new  principles  were  adopted.  Works  written  by  the  most 
eminent  physicians  a  century  ago,  are  now  considered  exceed- 
ingly imperfect,  so  much  so,  that  even  within  the  last  twenty- 
five  years,  the  science  of  medicine  may  be  said  to  have  been 
almost  entirely  revolutionized.  This  change  of  practice  will 
continue  until  it  shall  have  been  based  on  a  clear  understanding 
of  the  gi'eat  laws  of  health  and  disease. 

It  IS  my  purpose  to  represent  the  theory  and  practice  of  the 
most  eminent  physicians  of  the  present  day — 1860 — and  in  a 
mode  which  all  can  appreciate.  Against  the  errors  which  have 
been  heretofore  practiced,  I  shall  be  compelled  to  maintain  a 
steady  opposition,  and  shall  thus,  no  doubt,  fail  to  meet  the 
approbation  of  the  entire  profession.  This  I  expect — for  those 
who  have  been  educated  to  the  old  practice,  will  not  readily 
admit  that  they  had  really  not  understood  the  science  of  the 
healing  art.  When  we  see  the  leading  medical  men  of  the 
world  reversing  their  practice  and  suppressing  their  earlier 
works,  we  may  well  inquire  if  it  is  not  high  time  that  their 
disciples  and  pupils  were  beginning  to  question  their  own 
views. 

It  will  be  understood  that  there  are  principles  in  medical 
science  which  are  true,  and  these  are  the  same  now  as  in  the 
palmy  days  of  Hippocrates — for  truth  is  the  same  in  all  time 
and  in  all  countries ;  and  it  is  the  search  after  these  principles 
which  has  engaged  the  earnest  attention  of  so  many  eminent 
men  for  so  many  ages.  These  general  principles,  as  far  as  un- 
derstood, will  be  left  untouched,  except  as  they  can  be  used  to 
show  the  bearings  of  those  principles  which  have  been  more 
recently  discovered. 

It  is,  perhaps,  known  that  the  idea  of  eclecticism  has  been 
strongly  opposed  by  the  great  mass  of  American  physicians  y 


PKACTICE   OF    MEDICINE,  11 

yet,  within  a  few  years,  the  very  authorities  whom  physicians 
have  relied  on  have  abandoned  the  old  positions,  and,  to  a 
great  extent,  have  admitted  the  very  principles  for* which  the 
eclectic  branch  of  the  medical  profession  has  been  contending. 
At  this  moment  the  Medical  Faculty  of  the  University  of 
Edinburgh,  are  greatly  divided  upon  the  propriety  of  blood- 
letting in  the  treatment  of  pneumonia,  which  has  shown  at 
least  one  fact  which  ought  to  claim  our  attention,  viz :  That 
the  soundness  of  the  theories  upon  which  the  commonly  re- 
ceived text-books  on  practical  medicine  have  been  based,  are 
called  in  question  by  some  of  the  most  eminent  medical  men 
in  Europe.  The  question  seems  to  have  been  sprung  by  Dr. 
Bennet,  the  Professor  of  Clinical  Medicine  in  the  University 
of  Edinburgh,  and  Drs.  Alison,  Gairdner  and  others  have  been 
forced  to  take  part.  Let  it  be  understood  that  I  have  long 
opposed  the  use  of  the  lancet  in  the  treatment  of  pneumonia 
as  well  as  in  other  diseases,  as  I  have  the  indiscriminate  em- 
ployment of  mercury,  lead,  arsenic,  etc.,  and  that  others  had 
opposed  them  long  before  I  came  into  the  profession,  and  before 
Dr.  Bennet  had  ever  written  a  medical  essay  ;  and  it  will  be 
apparent  that  for  the  new  pathology  he  is  not  responsible,  the 
principles  and  old  theories  having  been  long  before  his  time 
exposed  by  Beach,  Morrow,  Jones  and  other  practitioners  in 
the  United  States — as  early  as  1830,  over  a  quarter  of  a  cen- 
tury ago".  It  is  not  for  me  to  say  why  they  opposed  the  doctrine  of 
Bronssais  and  others  of  his  school,  but,  from  their  publications, 
it  seems  to  me  that  they  were  governed  more  by  experience 
than  by  a  clear  comprehension  of  the  pathological  errors  then 
in  vogue. 

Since  1830,  many  facts  and  principles  in  physiology  have 
tended  to  a  more  perfect  understanding  of  that  science,  the 
result  of  which  has  been  a  clearer  conception  of  those  de- 
partures from  healthy  action  which  are  denominated  patholog- 
ical. In  the  outset  of  this  work  it  may  be  inquired  how  and 
in  what  way  we  are  to  be  guided  by  the  opinions  of  those  who 
have  written  on  medicine.  The  theories  that  have  been  ad- 
vanced from  age  to  age  are  almost  valueless,  but  the  facts  that 
have  been  adduced,  the  experience  that  has  been  recorded, 
should  weigh  very  heavily  with  those  engaged  in  teaching 
modern  medicine  ;  unless,  indeed,  we  accept  the  position  of 
Dr.  Alison,  who  broadly  affrms  that  the  tyjjes  of  disease,  and, 
therefore,  the  human  constitution,  have  undergone  marked 
changes  within  the  last  thirty  years.  If  such  be  a  fact,  the 
experience  of  those  who  practiced  thirty  years  ago  is  only  good 
so  far  as  their  own  times  were  concerned.  If  this  proposition 
of  Dr.  Alison  be  well  founded,  then  it  is  perfectly  apparent 
that  medical  science  can  never  be  otherwise  than  empirical,  an 


12  ECLECTIC   TREATISE    ON   THE 

inference  which  I  am  not  willing  to  admit.  But  that  Dr.  Ali- 
son has  been  able  to  find  many  of  his  old  pupils  to  testily  to 
the  correctness  of  his  position — the  change  of  the  type  of 
inflammatory  disease  is,  to  me,  no  wonder — and  as  the  settle- 
ment of  this  question  lies  at  the  very  basis  of  the  whole  practice 
of  medicine,  I  propose,  without  reference  to  the  arguments  of 
Dr.  Bennet,  to  show  that  Dr.  Alison  has  been  driven  into  an 
extraordinary  mode  of  bracing  up  his  position,  especially  on  ?■ 
question  of  such  scientific  importance. 

Uninterested  in  the  personal  merits  of  this  dispute,  I  am 
compelled  to  lay  aside  every  prejudice,  and  mediate,  to  my 
own  satisfaction,  at  least,  between  Dr.  Bennet  on  the  one  hand, 
and  Dr.  Alison  and  his  disciples  on  the  other.  Had  Dr.  Bennet 
modified  a  few  expressions,  his  theory  would  have  been  unob- 
jectionable. The  facts,  as  detailed  by  him,  are  essentially 
correct,  but  I  must  be  permitted  to  think  that  he  has  not  done 
all  that  was  in  his  power  for  the  elucidation  of  his  own  theor}', 
while,  also,  he  has  hardly  taken  Dr.  Alison's  proposition  for 
what  it  is  worth.  So,  too,  Dr.  Alison  stands  in  his  own  light 
by  the  bungling  way  in  which  he  has  arrived  at  his  prominent 
conclusion — ^from  insufficient  data.  If  Dr.  Alison  had  broadly 
asserted  that  the  phases  of  disease  had  been  modified  within 
the  past  thirty  years,  then  it  seems  to  me  that  his  position  would 
have  been  defensible.  Dr.  Alison  does  not  stand  alone  in  his 
position  any  more  than  does  Dr.  Bennet.  Both  are  warmly 
supported,  but,  unfortunately,  not  in  the  way  which  could 
strengthen  either.  Dr.  Watson,  Dr.  Symonds,  Sir  Chas.  Hast- 
ings, Sir  John  Richardson,  Dr.  Shann,  Mr.  Robertson,  Dr. 
Harvey,  Dr.  Fry,  Dr.  McCormac  and  Mr.  McFarlan,  in  their 
several  letters  to  Dr.  W,  P.  Alison,  in  t\iQ  Edhiburgh  Medical 
Journal^  only  reiterate  the  statement  of  Dr.  Alison,  that  the 
type  of  inflammatory  disease  has  changed  from  what  it  for- 
merly was  ;  and,  strange  to  say,  not  one  of  these  eminent  men 
has  attempted  to  give  us  the  rationale  of  that  change.  They 
have  contented  themselves  by  simply  asserting  that  patients 
laboring  under  inflammatory  disease,  do  not  bear  copious  blood- 
letting as  was  formerly  practiced,  and  that  therefore  the  type 
of  inflammatory  disease  has  changed.  This  is  coming  to  a 
conclusion  from  experience  it  is  true,  but  experience  of  a 
limited  and  very  imperfect  nature.  Both  parties  in  this  dispute 
have  truth  to  sustain  them,  both  are  governed  by  experience, 
and  it  remains  for  some  one  who  is  a  disinterested  observer  to 
bring  together  and  harmonize  the  statements  respectively  of 
Drs.  Bennet  and  Alison.  I  am  free  to  admit  the  difficulties 
which  present  themselves  are  enough  to  deter  me  from  the 
hazardous  attempt ;  nevertheless,  if  I  am  to  produce  a  book 
worthy  of  professional  confidence,  I  must  boldly  meet  this 


PKACTICE    OF    MEDICINE. 


13 


issue,  for  upon  tlie  settlement  and  adoption  of  one  or  the  other 
of  these  questions,  or  of  both  modiiied  and  subjected  to  the 
rigid  tests  of  reason  and  experience,  will  depend  the  soundness 
of  the  practice  which  I  am  about  to  present  to  the  medical 
public.  If  the  question  is  so  fraught  with  perplexities  and 
sources  of  error  as  to  deter  such  men  as  Alison,  Watson,  Gaird- 
ner,  McFarlan,  Hastings,  and  others  who  believe  with  Dr. 
Alison,  I  may  well  be  pardoned  if  I  fall  into  a  few  errors  as  to 
the  bearing  of  facts.  I  begin  by  committing  myself  to  the 
following  propositions,  which  I  shall  endeavor  to  elucidate 
afterward : 

First.  The  type  of  inflammatory  disease  has  not  changed. 

Second.  The  phases  of  inflammatory  diseases  have  changed. 

Third.  Inflammation  has  not  heretofore  been  well  under- 
stood. 

Fourth.  The  system  does  not  possess  the  stamina  now  that  it 
formerly  did,  and  does  not,  therefore,  bear  depletion  by  blood- 
letting as  it  formerly  did,  but  that  this  depends  on  modified 
surrounding  influences,  and  not  upon  any  actual  change  in  the 
type  of  disease. 

As  the  dogmatic  assertion  of  my  first  proposition  is  not 
to  be  taken  upon  my  mere  i'pse  dixit.^  I  shall  be  expected 
to  establish  it  by  argument,  by  fact,  and  by  inference.  I  there- 
fore enter  upon  the  task,  as  I  firmly  believe,  in  the  rejection  of 
opinions  merely  which  do  not  bear  investigation. 

Man  is  essentially  a  creature  of  conditions,  and  liable  to  the 
impression  of  many  influences.  Air,  water,  and  combustible 
matter  constitute  three  chemical  conditions,  neither  of  which 
he  can  dispense  with.  Let  us  imagine  a  mature  man,  in  the 
vigor  of  health  and  life — his  health  presupposes  the  supply  of 
air,  water  and  oxydizable  matter.  There  is  not  only  a  supply 
of  all  these  conditions,  but  there  is  a  true  relation  of  equili- 
brium between  them.  If  either  one  be  denied  him  his  body  is 
destroyed.  If  the  air  be  cut  off  he  is  no  longer  able  to  carry 
on  interstitial  oxydation — his  blood  ceases  to  circulate — he  dies, 
in  a  word.  If  the  water  is  denied  him,  the  processes  of  oxyda- 
tion, which  are  productive  of  heat,  being  uncontrolled,  he  is 
consumed  by  fever;  and  if  combustible  matter  be  denied  him, 
his  own  tissues  are  oxydized.  If  air,  then,  is  so  very  essential, 
we  are  not  troubled  to  perceive  how  he  is  affected  when  it  is 
changed  in  quality  or  quantity.  His  life  depends  on  the  inter- 
stitial oxydation  that  is  going  on  within  his  body,  and  this 
oxydation  depends  on  the  oxygen  which  he  derives  from  the 
atmosphere.  If,  therefore,  he  is  compelled  to  breath  an  atmos- 
phere poor  in  oxygen,  one  of  two  things  must  occur :  we  must 
furnish  him  with  material  for  digestion  which  is  more  readily 
oxydized,  or  else  a  lethargy  of  combustion  and  functional  action 


14  ECLECTIC   TSEATISE    ON   THE 

occurs,  which  unfits  the  system  for  excreting  and  secreting  as 
in  ordinary,  when  we  get  an  senemic  state,  and  presently  there 
is  obstruction  of  some  organ  or  apparatus,  and  we  get  inflam- 
mation or  fever  as  the  result.  So,  too,  if  allowed  to  breathe  air 
rich  in  oxygen,  and  he  also  be  furnished  with  a  plentiful  supply 
of  combustible  matter,  the  equilibrium  of  health  will  be  de- 
stroyed, and  fever  of  a  high  grade  sets  in.  Or  if  furnished  with 
a  plentifal  supply  of  air  and  water,  but  he  is  denied  combust- 
ible matter,  his  own  tissues  are  consumed,  and  he  dies  from  a 
low  grade  of  fever  in  the  end.  Let  us  bear  these  facts  in  mind, 
for  they  will  come  upon  us  forcibly  when  we  come  to  inquire 
into  the  nature  of  the  changes  which  inflammatory  diseases 
have  really  undergone.  That  oxygen  does  exercise  a  most 
important  influence  in  the  economy,  would  be  inferred  from  the 
fact  that  a  man  will  consume  over  eight  hundred  pounds  per 
annurn.  These  eight  hundred  pounds  of  oxygen  are  necessary 
to  oxydize  eight  hundred  pounds  of  solid  food  taken  in  during 
a  year,  and  to  control  this  combustion,  there  is  also  introduced 
fifteen  hundred  pounds  of  liquid — water,  etc., — in  the  same 
time,  thus  showing  the  introduction  of  over  a  tun  and  a  half 
of  matter  into  the  body  every  year,  which  alone  ought  to  be 
suflicient  to  point  out  the  immense  changes  constantly  going 
on  in  the  body.  Every  motion,  every  thought  is  at  the  expense 
of  the  organic  tissues,  and  hence,  this  immense  supply  of 
material  to  repair  such  wastes.  Truly,  in  the  language  of  Dr. 
Jno.  A.  Draper,  "  the  condition  of  life  is  death." 

There  is  also  thrown  out  or  excreted  during  the  same  time 
an  equal  amount  of  matter,  to-wit :  over  three  thousand  pounds, 
or  more  than  twenty  times  the  weight  of  his  own  body.  For 
the  excretion  of  this  large  amount  of  matter,  we  have  certain 
apparatus,  as  the  skin,  kidneys,  lungs,  salivary  glands,  etc., 
which  normally  excrete  matter  only  after  it  has  been  oxydized 
in  the  system,  and  whatever  appears  in  the  excretions  is  com- 
monly in  the  form  of  oxydes  ;  unless,  perhaps,  we  except  the 
milk  or  the  secretions  of  the  mammary  glands.  Yery  much 
of  the  fecal  matter  has  never  really  been  in  the  body  in  conse- 
quence of  its  being  non-combustible  at  a  temperature  of  100  deg. 
Fahrenheit. 

Everything  in  nature  is  in  a  state  of  mutation — ceaseless 
change  is  stamped  on  everything ;  but  the  laws  by  which  those 
changes  are  produced  are  as  immutable  as  truth  itself ;  and 
whenever  we  are  told  that  types  have  changed,  we  are  in  effect 
told  that  laws  have  changed,  which  is  simply  an  impossibility 
— a  scientific  absurdity.  Physiology  tells  us  that  no  article  is 
fit  for  food  that  will  not,  at  a  proper  degree  of  temperature, 
and  a  plentiful  supply  of  oxygen,  take  fire  and  burn,  giving 
out,  as  the  products  of  such  combustion,  carbonic  acid  gas  and 


PEACTICE   OF  MEDICINE.  15 

water,  or  these  with  nitrogen  or  its  compounds.  If  such  be 
the  fact,  and  no  one  questions  the  statement,  then  variations  in 
diet  will  produce  changes  in  nutrition,  and  therefore  in  organic 
actions.  Thus  the  Irish  people  have  changed  their  diet  within 
the  last  three  centuries,  and  the  phases  of  disease  depending 
on  suspended  or  perverted  nutrition,  have  been  correspondingly 
modified.  So  in  England  in  i-elation  to  the  use  of  tea,  and  in 
the  United  States  in  regard  to  coffee.  The  use  of  tobacco  has 
induced  vicarious  action  in  the  glands  of  the  throat  and  mouth, 
and  to  that  extent  have  the  phases  of  glandular  disease  been 
made  to  assume  new  phases.  Were  these  inferences  not  clearly 
deducible  from  the  facts,  why  do  we  order  particular  diets  in 
certain  diseased  conditions?  We  all  know  that  for  the  vitality' 
of  organization  there  are  required  many  saline  substances, 
which  are  to  be  introduced  in  a  state  of  solution.  This  intro- 
duction is  accomplished  by  water,  and  if  the  system  shall  be 
deprived  of  a  plentiful  supply  of  water  so  that  these  salts  cannot 
be  dissolved  and  deposited,  or  if  this  water  shall  be  either 
deprived  of  a  supply  of  saline  ingredients  or  too  thoroughly 
impregnated,  then  the  general  economy  will  be  equally  unfitted 
for  the  manifestation  of  healthy  action.  The  phenomena  of 
the  circulation  depend  on  oxydation,  and  if  the  air  introduced 
into  the  lungs  be  poor  in  oxygen,  combustion  will  be  retarded, 
and  every  vital  function  will  be  accordingly  modified.  This 
has  been  done  to  some  extent,  i.  e.,  the  air  has  been  impov- 
erished by  the  clearing  of  large  areas  of  country,  which  has 
not  only  left  a  surplus  of  carbonic  acid  gas  in  the  atmosphere, 
but  it  has  likewise  increased  the  extremes  of  heat  and  cold 
and  also  the  process  of  evaporation,  and  just  to  that  extent  has 
been  modified  the  phases  of  all  those  diseases  which  are  strictly 
of  a  febrile  or  dermoid  character.  Everybody  knows  the 
influence  exerted  over  evaporation  by  difierent  states  of  the 
atmosphere. 

If  we  live  on  a  diet  that  is  non-produetive  of  the  elements 
of  casein,  we. can  not  expect  that  the  milk  will  be  rich  in  that 
element.  Again,  when  a  man  is  fed  on  a  vegetable  diet,  there 
will  be  found  in  his  blood  much  less  fibrin  than  if  he  had  been 
fed  on  animal  food  ;  yet  the  blood  of  carnivorous  animals 
contains  less  than  that  of  herbivorous  animals,  while  birds 
have  the  most  of  all.  But  we  are  immediately  concerned  only 
80  far  as  man  is  interested.  The  people  of  the  United  States 
■eat  less  flesh  now  than  the  did  thirty  years  ago,  and  greatly 
less  than  they  did  sixty  years  since  ;  hence,  it  was  more 
abundant  in  the  blood  during  acute  inflammations  sixty  years 
ago  than  now.  Yenesection  was  formerly  resorted  to  in  order 
to  check  its  development,  bat,  as  is  now  generally  admitted, 
iu  vain. 


16  ECLECTIC   TBEATI8E   ON   THE 

The  plastic  power,  or  principle  of  life,  has  not  changed, 
though  whole  series  of  animals  and  vegetables  have  become 
extinct.  Coal  deposits  reveal  to  us  the  significant  fact  that 
there  has  been  withdrawn  from  the  air  an  immense  quantity  of 
carbon,  and  that  this,  to  some  extent,  may  account  for  the 
extinction  of  races  of  animals.  Again,  after  the  surface  tem- 
perature of  the  secondar}^  period  had  fallen  sufBciently  low, 
then  the  animal  kingdom  was  distributed  in  relation  to  the 
influence  of  the  sun's  rays.  At  the  time  the  carboniferous 
deposit  occured,  as  a  chemical  necessity,  there  was  an  immense 
evolution  of  an  equal  volume  of  oxygen  gas,  and  the  hot- 
blooded  animals  immediately  came  forth  as  the  result  of  favor- 
able conditions.  It  is  pretty  clearly  established  that  the  human 
race  has  sprung  from  a  standard  type,  and  that  all  the  departures 
from  that  standard  man  are  results  of  physical  influences,  with 
the  nature  of  which  every  physiologist  is  more  or  less  ac- 
quainted. Draper  and  Pritchard  think  that  ideal  type  may 
still  be  recognized.  !N^ott,  Glidden,  Agassiz  and  others,  con- 
tend that  there  are  many  types,  but  I  see  no  proof  of  this  ;  and 
admitting  it  to  be  true,  it  would  not  assist  Dr.  Alison's  posi- 
tion, since  any  number  of  types  less  than  the  individuals  of 
which  the  race  is  composed  would  still  be  modified  as  indi- 
viduals are  compared  with  the  standard  ;  and  if  one  has 
departed  from  the  true  type,  such  departure  must' have  a  definite 
cause,  which  would  operate  alike  on  all  of  his  tribe,  and  thus 
present  us  at  last  with  a  whole  tribe  that  had  departed  from  its 
type.  A  phase  difiers  Irom  a  type.  A  type  is  the  ideal  per- 
fection of  an  object — one  that  is  regarded  as  embodying  all  the 
elements  of  perfection,  and  hence,  Adam  is  regarded  as  the 
true  typical  man,  and  every  phase  of  humanity  is  only  a  modi- 
fication of  that  type.  A  phase  is  the  particular  aspect  which 
a  type  has  assumed  under  modifying  influences.  The  golden 
pippin  is  a  phase  of  a  type  represented  by  the  common  crab, 
and  if  the  influences  of  art  and  cultivation  be  removed  the 
pippin  returns  again  to  its  type — the  crab.  The  phases  would 
change  but  not  the  type. 

The  osseous  system  of  man  is  shown  by  those  derived  from 
the  Eastern  hecatombs,  as  mummies,  some  of  which  are  at 
least  three  thousand  years  old,  not  to  be  difierent  from  what  it 
is  now.  We  find  the  same  number  of  bones  as  at  present,  and 
for  them  much  the  same  composition,  except  in  those  perish- 
able products  which  have  been  dissipated  in  the  process  of 
decay.  In  a  word,  the  anatomy  of  man  was,  a  thousand  years- 
ago,  as  it  is  to-day,  and  if  his  muscles  are  less  developed  it 
follows  as  a  result  of  non-exercise,  etc.  In  this  way  man  has 
been  anatomically  modified,  but  his  type  is  the  same.  Every 
vital  process  has  always  been  executed  as  at  pre&eut,  the  celia. 


FRAOTICE    OF    MEDICINE.  17 

of  which  the  tissues  are  composed,  are  unchanged,  and  because 
they  are  not  so  violently  involved  in  disease  as  formerly,  we 
are  not  justified  in  saying  that  therefore  the  pathological  types 
are  changed.  Place  a  body  amid  influences  similar  to  those 
which  sun'ounded  men  three  thousand  years  ago,  and  diseases 
attacking  him  will  not  only  have  the  original  type,  but  they 
will  have  the  same  phases.  Again,  if  the  types  of  disease 
thus  change,  as  is  asserted  by  Drs.  Alison,  Watson  and  others, 
we  know  not  how  soon  some  new  and  universally  fatal  epidemic 
may  sweep  the  whole  race  from  the  face  of  the  earth.  If  it  be 
true,  what  Dr.  Watson  has  written  in  his  time  will,  in  all 
probability,  be  a  tissue  of  absurdities  in  the  times  of  his  great 
grandchildren ;  which,  for  the  honor  and  dignity  of  medical 
science,  I  am  not  willing  to  admit. 

If  changes  appreciable  to  our  senses  have  taken  place  in 
regard  to  the  type  of  disease  in  the  short  space  of  thirty  years, 
what  will  be  the  features  of  all  inflammatory  disease  one  thou- 
sand years  hence?  The  changes  observed  are  only  modifi- 
cations of  manifestation — the  type  is  the  same.  This  idea  may 
be  clearly  illustrated  by  another  application.  In  the  case  of 
insanity,  is  the  mind,  the  intellectual  principle,  changed,  or  is 
the  manifestation  merely  altered?  Evidently,  the  latter  thing 
occurs — the  intellectual  principle  is  the  same  in  both  cases. 
As  in  the  case  of  a  flute  in  the  hands  of  one  who  does 
not  understand  using  it,  the  instrument  gives  out  discordant 
sounds,  yet  those  same  sounds,  when  the  instrument  is  rightly 
handled,  are  reduced  to  great  harmony.  The  sound,  the 
muscial  element  is  the  same  in  both  instances,  but  the  mani- 
festations are  different.  The  type  remains  unchanged,  while 
the  phase  greatly  alters.  So  with  respect  to  the  type  of 
inflammatory  disease. 

I  have  asserted  that  the  nature  of  inflammation  has  not  been 
heretofore  well  understood,  and  the  various  theories  in  relation 
thereto  prove  my  position  most  conclusively.  The  quarrel 
between  the  parties  already  named  would  never  have  arisen 
had  this  been  so.  The  great  error  of  most  writers  on  the  sub- 
ject, has  been  in  treating  it  as  essentially  a  disease  jper  se^ 
instead  of  regarding  it  as  symptomatic  of  pathological  states. 
Now,  I  hold  that,  strictly  speaking,  no  inflammation  can  arise 
that  has  not  been  preceded  by  a  cause — that  the  inflammation 
is  a  result  of  a  cause,  and  in  its  treatment  we  should  medicate 
with  two  objects  in  view,  1.  To  remove  the  cause.  2.  To 
stay  its  progress  until  such  obstructions  or  causes  may  have 
been  removed.  The  various  medical  sects  have  arisen  in 
consequence  of  the  dissimilar  views  entertained  on  this  very 
question,  and  while  almost  every  theory  is  supported  by  more 
or  less  truth,  each  likewise  contains  much  that  is  erroneous, 


18  ECLECTIC   TREATISE   ON   THE 

and  from  a  wish  to  employ  the  truth  only,  I  have  been  com- 
pelled to  examine  and  re-examine  most  of  these  theories. 

The  stamina  of  the  physical  constitution  is  not  now  so  strong, 
generally,  in  this  country  as  it  formerly  was,  and  this  circum- 
stance is  explained  by  an  investigation  of  the  influences  bearing 
on  society  a  century  ago,  as  compared  with  those  influences 
which  impress  us  in  1860,  The  public  does  not  now  so  gen- 
erally resort  to  those  more  athletic  exercises — hunting,  running, 
jumpting,  lifting,  etc., — that  were  common  sources  of  amuse- 
ment one  century  ago.  The  public  is  less  exposed  to  the 
viscissitudes  of  weather  than  formerly,  the  diet  is  more  refined 
and  varied,  the  clothing  is  better,  often  thinner  however ; 
carriages  have  taken  away  the  practice  of  horseback  exercise 
to  a  great  extent ;  railroads  have  induced  us  to  take  frequent 
trips  from  home,  so  that  we  no  longer  see  children  engaged  in 
sports  which  were  common  in  bur  infancy.  Our  manners  and 
customs  have  undergone  a  serious  revolution,  and  every  change 
impresses  its  influence  on  our  constitutional  stamina. 

It  is  a  law  well  understood  by  physiologists,  that  where  the 
waste  is  greatest,  there  the  greatest  proportionate  quantity  of 
blood  will  be  sent.  If  one  of  the  limbs,  as  an  arm,  be  power- 
fully exercised,  the  waste  will  be  very  great,  and  there  will  be 
sent  an  increased  flow  of  blood  to  the  arm  at  the  expense  of 
all  other  parts  of  the  body.  So  if  the  brain  and  nervous  system 
are  almost  exclusively  exercised,  the  waste  will  be  proportionally 
repaired  by  an  increased  flow  of  blood  to  the  brain,  to  the 
depreciation  of  the  more  physical  part  of  the  body.  The 
muscles  decrease,  the  various  tunctions  of  secretion  and  excre- 
tion are  retarded,  and  of  course  the  entire  functional  equilibrium 
of  the  man  is  more  or  less  unbalanced.  Do  we  not  know  that 
the  brain  and  nerveous  system  have  been  very  greatly  exercised 
during  the  past  sixty  years,  and  that  this  is  being  daily  increased? 
and  just  in  that  proportion  is  the  constitutional  stamina  weak- 
ened,and  consequently  the  phases  of  disease  have  been  modified, 
as  is  recognized  by  every  intelligent  physician  who  will  take 
the  trouble  to  look  for  himself.  Hence,  while  blood-letting 
may  have  been  practiced  with  some  ingenuity  in  years  gone 
by,  it  is  certainly  an  exceedingly  injurious  practice  under  the 
weakened  constitutional  stamina  of  the  present  day.  And 
irrespective  of  the  arguments  adduced  by  Drs.  Bennet  and 
Alison,  the  reader  will  understand  why  this  is  the  case,  and 
at  the  same  time  escape  the  error  of  Dr.  Alison,  that  there  has 
been  a  change  in  the  type  of  inflammatory  disease,  or  that  of 
Dr.  Bennet,  that  there  has  been  no  change,  but  a  more  definite 
and  perfect  understanding  of  human  pathology. 

Having  said  this  much.  Dr.  Gairdner,  who  has  a  paper  in 
the  Edinburgh  Medical  Journal  for  September,  1857,  may  be 


PEACTICE    OF    MEDICINE.  19 

taken  to  task,  for  if  his  positions  are  right,  then  Dr.  Bennet  is 
wrong,  and  as  it  is  the  truth  that  I  am  seeking  to  elicit,  a  short 
paragraph  or  two  will  not  be  amiss  at  this  place.  Dr.  Gaird- 
ner's  paper  sets  out  with  the  declaration  that  "  blood  letting 
has  been  the  subject  of  a  never-ending  discussion  from  the 
earliest  ages  of  medicine  till  now."  If  this  declaration  is  true, 
we  are  enabled  to  come  readily  to,  at  least,  one  conclusion, 
which  will  palpably  present  itself  to  all  sane  minds,  that  it 
has  been,  at  all  times,  seriously  questioned,  and  that  even  in 
the  palmiest  days  of  the  practice,  there  were  men  who  would 
and  did  denounce  it  as  a  pathological  error — that  the  practice 
was  never,  at  any  time,  universally  admitted  by  all  physicians, 
which  is  presumptive  evidence  that  the  nature  of  the  results 
of  venesection  were  never  thoroughly  understood.  In  earlier 
ages,  the  practice,  as  is  admitted  by  Gairdner,  was  "  exti;ava- 
gantly  lauded" — they  claimed  more  for  it  than  it  deserved — 
and  this  is  now  known  to  have  been  the  case  with  Gregory, 
Broussais,  Bouillaud,  Rush  and  others,  of  a  later  date.  Vene- 
section produced  marked  and  visible  changes  which  were  at 
once  recognized  by  the  person  who  had  submitted  to  the  process, 
and  for  this,  if  for  no  other  reason,  it  became  somewhat  popular. 
K  one  labored  under  a  pleurisy,  a  copious  blood-letting  gave 
immediate  relief,  and  the  patient  and  physician  gave  attention 
to  the  immediate,  rather  than  the  remote  results. 

Upon  Dr.  Gairdner's  authority  I  am  justified,  however,  in 
making  the  statement  that  the  opposition  which  has  at  all 
times  been  urged  against  the  use  of  blood-letting,  has  been 
made  by  "  distinguished  leaders  in  medicine,"  and  we  may 
therefore  reasonably  conclude  that  the  opposition  was  based  on 
sound  reasons.  Nor  were  these  opponents  few  in  number,  for 
Dr.  Gairdner  tells  us  that  blood-letting  has  been  time  and 
again  consigned  to  oblivion  by  "  whole  generations  of  men," 
but  that  it  "  rose  again  into  an  estimation  more  considerable 
in  proportion  to  the  previous  neglect."  This  latter  statement 
shows  conclusively  that  the  history  of  venesection  has  been 
very  much  as  the  history  of  many  other  errors :  when  men  of 
moral  courage  rise  and  put  them  down,  it  is  at  most  only  a 
triumph  for  their  own  times,  since  others,  whose  only  aim  is 
money,  soon  set  them  on  foot  again  to  serve  their  selfish  or 
ambitious  ends.  Dr.  Gairdner  thinks  that  the  "  opinions  of 
any  one  man,  or  any  set  of  men,"  can  go  only  a  little  way  in 
deciding  the  question  of  blood-letting.  And  if  their  conclu- 
sions are  founded  on  "  opinions "  merely,  I  fully  agree  with 
him  ;  but  one  person,  wlio  has  carefully  investigated  a  subject, 
may  have  collected  facts  enough  to  decide  a  given  question 
with  great  certainty. 

Medical  men  in  all  ages  have  resorted  to  experimentation, 


20  ECLECTIC   TREATISE   ON   THE 

and  especially  so  in  later  years,  which  has  been  recorded  in 
our  literature.  Now,  if  we  endeavor  to  bring  the  facts  thus 
demonstrated  to  bear  on  a  particular  point,  the  one  who  may 
undertake  such  a  work,  will,  in  all  probability,  reverse  medical 
opinion  on  that  particular  point  to  a  considerable  extent.  This 
has  been  often  demonstrated  in  the  progress  of  medical  science, 
as  may  be  learned  by  the  labors  of  Harvey,  Bell,  Hall,  Car- 
penter, Davy,  Draper  and  others.  In  another  sense,  by  Hip- 
pocrates, Oullen,  Broussais,  Beach  and  others.  Upon  the 
doctrine  for  which  I  contend — the  immutability  of  the  types 
of  disease — these  experiments — the  collected  facts  brought  to 
light  by  the  labors  of  the  illustrious  dead — are  guide  posts  to 
direct  us  in  our  scientific  researches.  If  not  so,  why  do  we 
encumber  our  shelves  with  the  works  of  Hippocrates,  Thessalus, 
Chrysippus,  Erasistratus,  Yan  Helmont,  Galen,  etc.,  etc.?  If 
recorded  experience  is  valueless,  then  why  do  we  so  often 
quote  the  experience  of  those  who  have  gone  before  us  ?  The 
fact  is,  no  matter  what  Dr.  Gairdner  or  Dr.  Bennet  may  think, 
every  physician  relies  very  much  upon  the  observation  and 
experience  of  those  who  have  practiced  medicine  before  he  was 
born  ;  and  so  universally  is  this  principle  admitted,  that  even 
the  community  always  express  great  reliance  in  men  who  have 
had  much  experience  in  the  observation  of  disease.  Now,  it 
is  plain  that  if  the  type  of  disease  has  so  changed  within  thirty 
years  as  to  make  blood-letting,  which  was  formerly  a  sanitary 
operation,  now  inadvisable  and  dangerous,  then  it  is  plain  that 
the  experience  of  one  who  has  practiced  as  much  as  twenty 
years  not  only  does  not  add  to  his  medical  capacities,  but 
detracts  from  them,  making  him  really  a  dangerous  man  in 
society. 

In  this  country  no  one  questions  the  soundness  of  the  public 
instinct,  i.  e.^  when  the  strong  current  of  public  opinion  runs 
in  any  particular  direction,  it  is  invariably  in  the  direction  of 
right — in  the  pathway  of  truth.  It  is  true  that  when  a  propo- 
sition is  first  sprung,  multitudes  may  give  it  their  impassioned 
support,  but  a  little  time  for  calm  reflection  soon  decides  its 
fate.  The  same  is  true  of  all  men,  and  if  there  has  at  all  times 
been  such  decided  opposition  to  blood-letting  manifested  by  a 
large  part  of  every  community,  then  the  strong  presumption  is 
that  the  public  was  justified  in  that  opposition. 

Dr.  Gairdner  says,  "  it  may  be  freely  admitted  that  the  prac- 
tice of  the  present  day  tends  rather  in  the  direction  of  that  of 
the  Pythagoreans  and  monks,"  than  toward  the  sanguinary 
practice  of  the  Parisian  Faculty  in  the  time  of  Guy  Patin,  or  in 
later  times  by  Broussais  and  his  disciples.  He  further  admits 
that  medical  men  have  "  no  inducement  to  make  a  bigoted 
stand  in  favor  of  a  remedy  which  is  undeniably  not  in  fashion, 


PKAOTICE   OF   MEDICINE.  21 

one  which  they  themselves  now  employ  very  rarely."  In  the 
examination  of  these  declarations  and  admissions,  I  may  be 
allowed  to  inquire  why  the  medical  practice  tends  to  the  non- 
sanguinary  practices  of  the  Pythagorean  school  i  Is  it  because 
we  know  more  of  the  science  of  human  pathology,  or  is  it 
because  the  type  of  disease  has  changed,  or  rather  is  it  not 
the  result  of  a  more  perfect  understanding  of  the  pathological 
states  present  in  disease,  and  an  appreciation  of  the  modifica- 
tions in  the  phase  of  disease  ?  If,  also,  blood-letting  is  em- 
ployed so  "very  rarely,"  as  Dr.  Gairdner  admits  it  to  be,  then 
has  the  profession  come  to  the  acknowledgment  of  its  injurious 
results,  or  do  they  withstand  the  temptation  simply  because  it 
is  "  undeniably  not  in  fashion  ?"  If  it  is  so  "  very  rarely  em- 
ployed," then,  in  the  name  of  common  sense,  why  do  Dr. 
Gairdner  and  his  friends  wage  such  a  merciless  war  on  Dr. 
Bennet?  Dr.  Gairdner  admits  that  there  never  was  a  more 
favorable  opportunity  for  banishing  the  practice  than  now,  and 
he  thinks  that  Dr.  Bennet  might  have  raised  the  standard  of 
Yan  Helmont  or  Erasistratus,  and  have  quietly  floated  down 
the  stream  of  public  opinion  with  as  much  certainty  of  reaching 
eminence,  as  by  an  attempt  to  revolutionize  medical  science. 
This  all  does  very  well  for  one  who  finds  himself  unable  to 
answer  the  arguments  of  another,  and  therefore  relies  on  the 
shafts  of  ridicule ;  but,  in  science,  such  proceedings  have  little 
weight.  Besides,  in  all  seriousness,  if  it  had  been  such  an 
easy  matter  to  attain  medical  eminence  by  smoothly  floating 
down  the  stream  of  public  opinion,  why  should  Dr.  Bennet 
have  undertaken  the  herculean  task  of  revolutionizing  medical 
science  ?  That  fact  alone  shows  Dr.  Bennet  to  be  an  honest 
advocate  for  medical  reform,  and  I  honor  the  man  for  the  pains 
he  has  taken  to  expose  the  errors  upon  which  the  old  pathology 
was  founded,  and,  consequently,  the  old  practice. 

There  is  a  circumstance  connected  with  this  subject  to  which 
I  must  call  attention,  inasmuch  as  it  provides  me  an  opportunity 
to  inquire  into  the  philosophy  of  the  phenomena.  This  is  what 
I  refer  to:  The  discussion  of  the  theory  of  venesection, instead 
of  preceding^  has  followed^  the  change  in  practice.  Dr.  Gaird- 
ner says  that  this  is  an  "  undeniable  fact,"  and  one  which  he 
says  Dr.  Bennet  also  admits,  and  I  also  add  my  testimony  to 
its  truthfulness.  Now,  this  is  the  only  answer  that  is  needed 
to  the  question,  why  is  this  so?  The  practice  of  a  physician 
is  supposed  to  be  founded  on  good  judgment  and  a  definite 
knowledge  of  the  nature  of  the  various  diseases,  and  after  he 
has  been  long  engaged  in  practice  it  is  a  most  difiicult  labor 
for  him  to  admit  his  previous  ignorance,  notwithstanding  he 
may  have  abandoned  the  errors  of  his  practice.  Hence,  in  the 
case  of  blood-letting,  we  find  that  after  the  case  has  become 


22  ECLECTIC   TREATISE   ON   THE 

obsolete,  .and  one  can  hardly  take  advantage  of  another,  then 
all  feel  willing  to  engage  in  a  dispute  in  relation  thereto,  those 
having  renounced  it  first  being  the  leaders  in  forcing  the 
discussion,  while  those  who  have  but  recently  quit  it  are  com- 
pelled to  offer  some  sort  of  explanation,  as  in  the  case  of 
Drs.  Alison,  Gairdner,  Watson,  Hastings  and  others.  Dr. 
Gairdner,  in  his  strictures  on  Dr.  Bennet,  which  are  almost  too 
personal  to  answer  his  purpose,  says  that  we  are  "  only  now 
beginning  to  inquire  into  its  causes" — that  is,  the  revolution 
which  has  taken  place  in  regard  to  blood-letting.  That  may 
be  true  so  far  as  Scotland  is  concerned,  but  in  the  United 
States  this  subject  has  been  most  thoroughly  canvassed  since 
1825 — over  a  quarter  of  a  century  ago.  So  thorough  has  been 
the  discussion,  so  violent  has  been  the  opposition,  that  nearly 
a  dozen  medicaV  colleges  have  been  founded  to  break  down  the 
old  practice ;  and  now  no  section  of  country  is  destitute  of  its 
reform  physician.  The  public  has  began  to  understand  the 
difference,  and  to  discriminate  between  them  when  their  services 
are  required. 

Dr.  Gairdner  takes  Dr.  Bennet  to  task  for  saying  that  this 
revolution  has  been  brought  about  by  "an  advanced  diagnosis 
and  pathology,"  but  certainly  the  former  gentleman  would  not 
have  the  hardihood  to  deny  that  we  have  made  very  great 
advances  in  both  our  means  and  knowledge  of  diagnosis  and 
pathology.  The  stethescope  and  microscope  have  revealed  the 
existence  of  many  conditions  which  were  previously  unknown  ; 
and,  therefore.  Dr.  Bennet  is  right  in  his  position,  it  seems  to 
me.  Dr.  Bennet  and  Dr.  Gairdner  are  diametrically  opposed 
in  relation  to  abuses  and  the  stethescope,  the  former  contending 
that  as  the  stethescope  revealed  the  true  nature  of  many  diseases, 
it  put  an  end  to  the  abuses  in  the  treatment  thereof;  which 
declaration,  it  seems  to  me,  constitutes  a  self-evident  proposi- 
tion ;  but  Dr.  Gairdner  asserts  that  it  "  led  directly  to  their 
extension — a  vast  field  of  hitherto  unnoticed  diseases  being 
brought  to  light."  This  declaration  is  so  inconsistent  with  com- 
mon sense,  that  I  dismiss  it  without  a  comment.  It  will  be 
understood  by  the  readers  of  this  volume  that  we  have  a  class 
of  physicians  in  the  United  States  who  term  themselves  eclec- 
tic, and  whose  characteristics  have  been  drawn  by  Renouard, 
in  his  History  of  Medicine,  in  these  words :  "  They  drew  irom 
each  (system)  what  to  them  seemed  to  be  most  conformable 
to  reason  and  experience" — subjecting  everything  to  the  tests 
of  common  sense  and  experiment.  The  eclectic  school  in 
modern  times  has  many  characteristics  that  did  not  belong  to 
that  school  in  its  earlier  days.  The  modern  eclectic  not  only 
claims  affinity  with  whatever  is  true  in  the  philosophy  of  any 
or  all  of  the  sects,  but  he  claims,  as  a  sequence  of  such  im- 


PRACTICE    OF   MEDICINE.  23 

partial  examination  of  all  systems,  that  his  philosophy  leads 
to  the  only  possible  establishment  of  a  homogeneous  practice. 
He  claims,  and  with  good  grace,  that  the  constant  comparison 
of  rival  systems  enables  him  to  perceive  and  lay  aside  his  own 
errors  of  opinion — that  in  the  bickerings  of  the  sects,  he,  as  a 
dispassionate  judge,  is  enabled  to  decide  the  merits  of  questions 
in  discussion.  He  is  also  led  to  the  perception  of  principles 
not  visible  through  the  prejudices  ot  sectarianism ;  hence,  he 
claims  the  character  of  a  discoverer,  boldly  advancing  his 
attempts  to  render  more  positive  and  efficient  the  materia 
medica  of  the  profession,  and  a  more  rational  pathology.  He 
claims  that  it  is  only  by  a  comprehension  of  a  rational  pathology 
that  any  man  can  become  a  rational  practitioner. 

It  is  the  aim  of  every  department  of  a  medical  education  to 
prepare  the  student  for  the  exercise  of  a  rational  practice.  A 
man  may  be  a  great  anatomist,  pathologist,  physiologist,  etc., 
but  if  he  is  not  a  master  of  general  and  special  therapeutics 
and  a  good  chemist,  his  practice  will  be  irrational,  and  at  most 
only  experimental.  The  actual  treatment  of  disease,  is  the 
desideratum  in  a  physician's  education,  and  he  can  never  be  a 
good,  reliable  and  judicious  practitioner  if  his  practice  is  based 
on  erroneous  pathology,  and  he  relies  on  uncertain  agencies  to 
effect  those  changes  which  must  be  induced  to  re-establish  phys- 
iological conditions.  Hence,  every  author  of  a  work  on  prac- 
tice should  clearly  set  forth  the  basis  of  that  practice  by  giving 
a  rational  pathology  of  every  disease.  This  is  usually  attempt- 
ed in  the  introductions  to  such  works,  but  clearly,  this  practice 
is  wrong,  since  the  special  pathology  of  particular  diseases  is 
thereby  neglected ;  hence,  it  has  been  my  aim  to  make  this 
introductory  chapter  the  vehicle  for  the  discussion  of  general 
pilnciples,  reserving  special  pathological  considerations  for 
that  portion  of  the  work  devoted  to  the  investigation  of  special 
disease. 

It  is  no  longer  denied  by  intelligent  practitioners,  that  very 
great  changes  have  recently  taken  place  in  the  practice  of 
medicine  both  in  Europe  and  America.  Nay,  more,  dm*ing 
the  progress  of  this  change  hardly  any  two  works  on  the  theory 
and  practice  of  medicine  are  alike,  and  certainly  in  the  main, 
they  do  not  correspond  with  the  practice  which  we  see  the  most 
eminent  men  engaged  in  propagating.  It  is  also  true  that  the 
young  man  who  educates  himself  from  books  and  one  who  is 
educated  by  lectures,  differ  as  widely  as  do  the  philosophies  of 
modern  and  ancient  medicine.  This  schismatic  tendency  of 
European  and  American  medical  science,  arises  from  the  ana- 
lytical character  of  the  European  and  American  mind,  which 
leads  us  to  ask  questions,  to  demand  proofs,  to  institute  demon- 
strative experiments,  to  analyze  propositions,  to  trace  generaU- 


24         ECLECTIC   TREATISE    ON   THE    PEACTICE   OF   MEDICINE. 

ties  back  to  their  special  elements — towage  a  ceaseless  war  on 
everything  not  consistent  with  reason  and  experience.  Anala- 
gous  circumstances  present  themselves  in  reference  to  our  po- 
litical systems,  our  domestic  institutions,  our  general  philoso- 
phies, and  it  is  as  true  that  we  are  passing  through  a  definite 
scientific  development,  as  that  we  are  passing  through  a  defi- 
nite political  development.  A  certain  period  in  this  analytic 
stage  will  usher  in  the  syntheticism  of  the  Asiatics,  when  we 
shall  no  longer  ask  questions,  but  simply  use  affirmations. 
This  will  be  the  result  of  demonstrative  experiments,  isolated 
cases  of  which  are  even  now  to  be  found,  e.  g.^  every  school 
and  class  of  physicians  affirm  that  the  brain  is  the  instrument 
through  which  the  mind  is  manifested,  yet  that  proposition  is 
less  than  one  century  old.  All  physicians  unite  in  affirming 
that  ippecacuanha  is  an  emetic,  that  quinine  is  a  tonic,  that 
iodine  is  an  alterative,  etc.  These  propositions  have  been  clearly 
demonstrated,  and  our  analyticism  is  completely  satisfied.  So, 
in  time,  will  be  almost  every  proposition  in  medical  science ; 
discussion  leads  to  the  establishment  of  these  propositions,  and 
hence,  we  have  everything  to  gain  and  nothing  to  lose  by 
legitimate  discussion.  I  mean  by  the  term  legitimate  discus- 
sion, such  as  is  conducted  with  fairness,  and  where  both  parties 
are  really  desirous  to  elicit  the  truth.  When  such  disputes, 
however,  are  stripped  of  the  urbanities  and  courtesies  that 
ought  to  characterize  the  doings  and  sayings  of  gentlemen, 
when  they  sink  into  personal  reflections  and  disagreeable 
inuendoes,  when  the  slang  of  billingsgate  takes  the  place  of 
dignified  language  and  logical  statement,  then  these  discus- 
sions are  productive  of  great  evils. 


CHAPTER    II. 


The  reader  will  not  forget  that  I  have  already  shown  that 
Dr.  Bennet  is  not  the  originator  of  the  new  pathological  views- 
which  I  shall  here  present,  yet  he  may  justly  be  considered  the 
champion  thereof  in  Europe  at  this  time.  While  Alison,  the 
venerable  exponent  of  the  olden  pathology,  will  be  readily 
admitted  as  the  most  consistent  representative  in  Europe,  yet 
we  have  been  less  impressed  by  his  direct  influence  than, 
through  the  labors  of  some  of  his  pupils.  In  Europe  the 
profession  manages  its  discussions  with  more  judgment  and 
circumspection  than  we  do  in  America.  There  the  im- 
provement is  started  in  the  medical  society,  while  in  the  United 
States  it  originates  in  a  closet  and  is  first  thrown  out  in  a  book 
or  through  the  pages  of  a  medical  journal.  The  result  is,  the 
author  is  handled  by  the  critics  without  gloves,  and  before  he 
has  had  time  to  make  a  dispassionate  reply,  the  conti'oversy 
becomes  personal  and  he  is  no  longer  able  to  do  either  himself 
or  his  subject  that  justice  which  both  merit. 

Were  I)r.  Bennet  a  professor  in  the  University  of  Pennsyl- 
vania as  he  is  in  the  University  of  Edinburgh,  he  would  have 
been  long  since  expelled,  or  had  he  been  a  member  of  the  Amer- 
ican Medical  Association,  as  he  is  of  the  Medico-Chirurgical 
Society  of  Edinburgh,  where  his  paper  was  read,  he  would  have 
received  his  dismissal  the  following  day,  for  if  he  is  right,  the 
great  body  is  wrong,  which,  even  though  true,  would  hardly 
have  been  admitted. 
2 


26  ECLECTIC    TREATISE    ON    THE 

As  Dr.  Bennet  has  defended  the  very  positions  taken  by 
^Beach  and  his  disciples  nearly  thirty  years  ago,  though  sus- 
tained by  difierent  arguments,  I  take  pleasure  in  presenting 
some  of  the  more  material  points  in  his  paper  read  before  the 
Medico-Chirurgical  Society  of  Edinburgh,  on  "  the  results  of 
an  advanced  diagnosis  and  pathology  applied  to  the  manage- 
ment of  internal  inflammations,  compared  with  the  eflects  of 
a  former  antiphlogistic  treatment,  and  especially  of  blood- 
letting.-' Prof.  Bennet's  paper  was  elicited  by  a  paper  fi'om 
the  venerable  Alison,  published  in  the  early  part  of  1856,  in 
which  he  undertook  to  show  that  the  type  of  inflammation  had 
changed.  It  is  admitted  everywhere  among  physicians  of 
learning  in  the  present  day,  that  while  it  was  formerly  the  rule, 
in  the  treatment  of  inflammatory  diseases,  to  bleed  early, 
largely  and  repeatedly — that  now  such  bleeding  is  rarely  prac- 
ticed and  is  never  necessary.  This,  remember,  is  the  admission 
of  Alison,  the  teacher  of  Watson,  Hamilton,  Fry,  Hastings 
and  other  great  names.  Was  it  not  lor  this  very  declaration 
that  Beach  was  anathematized  in  America  thirty  years  ago  ? 
Was  it  not  Alison,  Watson  and  similar  authorities  that  were 
arrayed  against  Beach  in  this  country  ?  And  is  not  the  admis- 
sion a  clear  vindication  of  Beach's  observations?  Is  it  not 
strange  that,  with  such  admissions  from  such  men,  the  profes- 
sion still  make  spasmodic  eflbrts  to  sustain  an  old  theory  of 
Alison,  when  he,  himself,  admits  its  error? 

Dr.  Alison  perceives  the  dilemma  in  which  his  disciples  are 
placed,  and  with  all  the  eflbrts  of  a  great  mind  he  comes  up 
manfully  to  their  rescue  by  asserting  that  his  theory  was  true, 
but  that  the  type  of  inflammation,  and  especially  of  the 
accompanying  fevers,  have  changed  from  inflammatory  to  a 
typhoid  character.  I  have  already  shown  the  absurdity  of  this 
proposition,  and  shall  pursue  it  further  through  these  pages. 
This  proposition  is  set  up  with  appai-ent  candor  by  Dr.  Alison, 
to  defend  the  old  therapeutic  rules  ;  for  if  it  be  established 
that  those  rules  wei*e  wrong,  then  Dr.  Alison  has  been  in 
error  all  his  life,  and  what  he  may  have  written  is  merely  a 
record  of  that  error.  Dr.  Alison  must  have  seen  this,  and 
hence,  to  brace  up  his  position,  he  has  been  compelled  to  use 
the  aiiidavits  of  his  old  pupils. 

Dr.  Bennet  lays  down  five  propositions,  from  which  he  pro- 
ceeds to  reason.  These  are,  1.  That  little  reliance  can  be 
placed  on  the  experience  of  those  who,  like  Culleu  and  Gregory, 
were  unacquainted  with  the  nature  of,  and  the  mode  of  detect- 
ing internal  inflammations.  2.  That  inflammation  is  the  same 
now  as  it  has  ever  been,  and  that  the  analogy  sought  to  be 
established  between  it  and  the  various  types  of  essential  fevers 
is  fallacious.  3.  That  the  principle  on  which  blood-letting  and 
antiphlogistic  remedies  have  hitherto  been  practiced,  is  op- 


PKACTICE   OF   MEDICINE.  27 

posed  to  a  sound  pathology.  4.  That  an  inflammation  once 
established  cannot  be  cut  short,  and  that  the  only  object  of 
judicious  medical  practice  is  to  conduct  it  to  a  favorable  ter- 
mination. 5.  That  all  positive  knowledge  of  the  experience 
of  the  past,  as  well  as  the  more  exact  observation  of  the  present 
day,  alike  establish  the  truth  of  the  preceding  propositions  as 
guides  for  the  future. 

If  Dr.  Bennet  had  admitted,  as  no  doubt  he  will,  eventually, 
that  the  phase  of  inflammatory  disease  has  somewhat  changed, 
his  propositions  would  only  require  re-statement  to  repeat  the 
principles  on  which  the  eclectic  branch  of  the  medical  profes- 
sion rests  its  claims  to  respectlul  consideration. 

Until  recently,  inflammation  has  been  recognized  by  pain, 
heat,  redness  and  swelling,  especially  when  external,  and 
internally  when  fever  was  present,  accompanied  by  pain  and 
impeded  function  of  the  organ  afl'ected.  The  nosological  sys- 
tems were  purely  artificial,  and  as  these  chanced  to  vary,  so 
the  essential  characteristics  of  inflammation  were  made  to 
vary.  This  led  to  confusion  and  endless  error ;  but  the 
researches  of  morbid  anatomists  have  shown  that  inflayimation 
ia  never  jjresent  except  when  the  inflamed  part  is  in  a  morbid 
condition — that  it  is  a  result  of  such  morbid  derangement; 
that  it  is  a  symptom ;  that  it  results  from  a  concentration  of 
the  plastic  power  ;  that  it  is  not  a  disease  per  se,  but  the  result 
of  an  extraordinar}'  eftbrt  of  the  system  to  maintain  its  integ- 
rity; that  it  is  the  natural  result  of  organic  lesions,  and  in 
treating  it  we  shall  regard  it  as  symtomatic  of  a  morbid  state 
at  all  times,  as  will  be  clearly  shown  in  an  examination  of  the 
points  of  consideration  introduced  by  Dr.  Bennet. 

Dr.  Bennet  says  "  the  school  of  morbid  anatomy,  by  showing 
that  inflammation  was  a  diseased  condition  of  a  part,  entirely 
overthrew  the  errors  and  confusion  inherent  in  all  such  noso- 
logical 83'stems."  The  actual  observation  of  physicians  by  the 
patients'  bedside,  aided  by  the  increased  facilities  of  diagnosis 
and  correct  pathology,  has  demonstrated  beyond  a  rational  doubt 
that  the  nosological  group  of  symptoms  formerly  supposed  to 
indicate  internal  inflammation,  bears  no  relation  thereto,  in 
fact ;  and  these  investigations  have  further  developed  a  large 
mass  of  information  that  has  never  yet  been  systematized,  but 
is  scattered  here  and  there  through  the  writings  of  various 
modern  ph3'sicians.  This  is  a  position  taken  by  Bennet,  and, 
to  my  mind,  it  is  well  founded.  Now,  in  any  sense,  can 
inflammation  be  called  a  disease  or  not?  It  certainly  is  not  a 
disease  per  se,  but  it  is  a  morbid  condition.  It  is  a  symptom 
of  a  morbid  state,  and  may  be  called  a  disease,  or  regarded  as 
one ;  in  fact,  if  we  only  bear  in  mind  that  histology  has  exhib- 
ited to  us  the  tact  that  inflammation  is  a  disease  of  nutrition, 
governed  by  the  same  laws  that  determine  the  growth  and 


28  ECLECTIC    TBEATISE    ON    THE 

function  of  cells — i.  e.,  what  Dr.  Draper  calls  the  plastic 
power — and  that  in  this  sense  physiology  and  pathology  are 
united  into  one  science  that  has  enabled  us  to  get  still  further 
out  of  the  traditional  errors  of  the  past. 

From  this  statement,  Dr.  Bennet  asks  the  significant  ques- 
tion, "Why,  then,  should  we,  in  our  onward  course,  be  governed 
by  the  opinions  of  Cullen  and  Gregory,  of  Gabius  and  Syden- 
ham, of  Aretseus  and  Hippocrates  (  "  Certain  it  is,  that  while 
those  distinguished  men  stood  at  the  head  of  their  profession 
in  their  day  and  generation,  yet  the  imperfections  of  science 
were  such  that  they  would  commit  many  very  great  mistakes ; 
and  because  they  were  great  and  learned  in  their  day,  shall  it 
be  said  that  we,  with  all  the  lights  of  tha  nineteenth  century, 
are  bound  down  to  their  errors  simply  because  they  have  the 
sanction  and  authority  of  the  antique?  Absurd  as  it  may 
seem,  this  is  just  what  Dr.  Alison  and  his  followers  would 
have  us  do.  With  equal  propriety,  navigators  ought  this 
day  to  be  compelled  to  act  on  the  exploded  astronomical  notions 
ot  Tycho  Brache  and  Copernicus,  which  would  be  simply 
ridiculous. 

Those  who  have  heretofore  written  on  medicine,  have  treated 
the  errors  of  olden  physicians  with  too  much  consideration, 
always  feeling  that  they  must  disprove  the  old  theories  and 
rules  before  they  should  advance  the  new  ones.  The  amount 
of  labor  thus  uselessly  expended  has  been  very  great.  Now, 
it  is  apparent  that  the  establishment  of  the  new  theory — the 
advancement  of  the  more  demonstrable  principles,  would,  in 
the  very  nature  of  things,  have  consigned  the  old  doctrines 
to  merited  oblivion.  It  is  for  this  reason  that  I  shall  not  enter 
into  any  lengthened  exposition  of  the  errors  of  the  leaders  of 
the  profession,  Irom  Hippocrates  down  to  Alison.  Alison, 
however,  living  late  enough  to  observe  the  war  of  the  new  on 
the  old  pathology,  may  yet  correct  his  previous  teachings,  and 
thus  re-instate  himself  in  the  van  ot  his  profession. 

By  inflammation,  is  meant  an  exudation  of  the  normal 
liqour  sanguinis.  This  is  what  Bennet  understands  it  to  be — 
it  is  what  Alison  seems  to  understand  it  to  be  when,  as  Bennet 
says,  he  acknowledges  "  that  exudation  of  lymph  is  essential 
to  almost  all  changes  of  structure  produced  by  inflammation.'' 
Bennet  again  says,  "both  Dr.  Alison  and  myself  (by  the  term 
inflammation),  mean  a  change  in  a  part  characterized  by  the 
exudation  of  lymph  through  the  walls  of  the  minute  vessels, 
resulting  Irom  changes  more  or  less  well  marked  in  the 
nervous,  vascular,  sanguineous  and  parenchymatous  elements 
of  that  part."     To  this  I  lully  agree. 

Diagnosis  will  vary  in  correctness — as  a  basis  of  opinion,  as 
our  knowledge  of  special  and  general  pathology  is  more  or 
less  perfect.     Thus,  until  recently,  internal  inflammation  was 


PKACTICE    OF   MEDICINE.  29 

never  sought  after  except  through  the  manifestation  of  symp- 
toms. But  our  modern  investigators,  who  have  pushed  their 
inquiries  to  a  very  great  extent,  show  most  conclusively  that 
symptoms  are  not  to  be  relied  on  alone,  since,  where  all  the 
symptoms  of  inflammation  have  been  present,  jet  post  mortem 
examination  has  demonstrated  the  absence  of  the  lesion. 
Again,  inflammation  has  caused  many  deaths,  without  one  of 
the  symptoms  supposed  to  always  accompany  it  having  been 
present.  This  is  admitted  now,  by  even  those  who  endeavor 
to  bolster  up  the  old  practice.  We  know,  and  as  Dr.  Alison 
admits,  that  we  can  now  detect  the  presence  of  inflammation 
of  the  lungs  where,  in  days  gone  by,  we  should  have  never 
dreamed  of  the  existence  of  pneumonia,  and  simply  because 
there  was  neither  pain,  cough,  dyspncea,  or  inflammatory  fever 
present.  But,  with  the  stethescope — with  the  light  thrown 
out  by  the  researches  of  morbid  anatomists — we  now  detect 
the  presence  of  the  inflammation,  even  though  complicated, 
as  it  usually  is,  by  other  phases  of  disease.  Dr.  Alison  thinks 
that  cases  thus  overlooked  were  attended  with  very  little  im- 
mediate danger  ;  but  this  assertion  is  certainly  not  well  found- 
ed, since,  even  now,  the  latent  pneumonias  are  the  most  fatal, 
and,  as  Dr.  Bennet  says,  "  must  always  have  been  so."  Again, 
the  pain,  cough,  dyspnoea,  rusty  sputa  and  fever,  which  are, 
or  have  been,  regarded  as  characteristic  of  pneumonia,  are 
met  with  in  various  other  morbid  states,  and  where  inflam- 
mation of  the  lungs  is  not  present ;  and  Dr.  Bennet  mentions 
as  illustrations  the  bronchitis  of  young  persons,  the  engorge- 
ment and  apoplexy  of  the  lungs,  associated  with  fever  or  heart 
disease  in  older  persons.  It  will,  therefore,  be  seen  how  many 
a  patient  was  previously  bled  for  a  pneumonia  when  none  was 
present,  and  how,  in  other  cases,  blood-letting  was  not  prac- 
ticed when  pneumonia  was  actually  present.  It  is  said  by 
many  advocates  of  the  old  practice  that  Pneumonia  is  not  now 
what  it  formerly  was.  I  admit  that  the  phases  thereof  are 
somewhat  modined,  from  causes  already  enumerated ;  but  does 
not  the  dift'erence  consist  in  our  more  perfect  acquaintance  with 
the  disease,  and  greater  facilities  of  diagnosis,  than  in  any 
actual  change  in  the  type  of  inflammation  of  the  lungs  ?  I  ad- 
mit that  we  call  certain  diseased  states  pneumonia  in  1859, 
which  in  1759  were  either  unnoticed,  or  refeiTed  to  some  other 
tissues  than  the  lungs ;  and  the  reason  of  this  is  plain  enough. 
Then,  if  so  little  was  known,  comparatively,  by  the  older  phy- 
sicians, how  shall  we  be  enabled,  from  their  experience,  to  treat 
disease  in  1859  rationally,  since  we  know  the  disease  not  to  be 
what  it  was  formerly  thought  to  be  i  The  only  way  in  which 
the  experience  of  the  past  can  be  useM  to  us  is  by  bearing  con- 
stantly in  mind  what  was  really  known,  and  from  the  practice  of 
ancients,  and  its  results,  we  shall  be  enabled  to  glean  some- 


30  ECJLECTIC    TKEATISE    ON    THE 

thing  of  the  action  of  medicines  on  diseased  conditions  which  the 
ancients  did  not  really  understand.  We  have  to  deal  with  liv- 
ing men  in  the  present  day,  and  hence  our  studies  should  tend 
to  the  investigation  of  the  diseases  atiectiug  men  now,  rather 
than  in  commenting  on,  and  following  the  opinions  of  men  in 
Oiher  ages,  whom  we  know  to  have  been  destitute  of  much  that 
is  now  known.  We  must  examine  diseased  conditions  as  we 
find  them,  and  this  fact  is  apparently  admitted  in  the  desire  shown 
by  so  many  authors  to  publish  their  own  experience  in  the  healing 
art.  It  is  only  now  that  we  are  beginning  to  be  able,  with  the 
special  researches  of  the  most  enlightened  men,  to  judge  cor- 
rectly of  the  value  of  old  dogmas,  and  to  confidently  advance 
new  rules  and  practices.  Experience  is  worth  something  only 
as  the  experimenter  has  comprehended  the  subject  of  his  ex- 
periments ;  or,  in  other  words,  the  experiences  of  one  who 
has  had  the  advantages  of  "  an  advanced  diagnosis  and 
pathology,"  as  Dr.  Bennet  says,  is  evidently  worth  more  than 
one  who  has  had  no  guides  better  than  the  theories  of  Hip- 
pocrates. 

It  has  already  been  stated  that  a  series  of  changes  in  the 
nervous,  sanguineous,  vascular  and  parenchymatous  functions, 
terminating  in  exudation  of  the  liquor  sanguinis,  constitute  the 
essential  natm-e  of  inflammation.  Dr.  Bennet,  in  the  argu- 
ment of  his  second  proposition,  asks,  "how  it  can  be  shown 
that  any  of  these  necessary  changes  have,  of  late  years,  under- 
gone any  modifications  i "  e.  g.,  if  a  healthy  man  receive  a 
blow,  a  cut,  a  bruise,  or  any  other  injmy  to  his  person,  are  the 
resulting  phenomena  in  any  sense  diil'erent  li'om  what  they 
were  in  the  time  of  Hippocrates,  Galen,  CuUeu  or  Gregory  ? 
There  is  a  difl'erence  only  in  the  intensity  of  those  phenom- 
ena. Bennet  asks :  "  Are  the  efiects  which  followed  wounds 
received  at  the  battle  of  Alma  difi'erent  li'om  those  which  re- 
sulted from  similar  injuries  at  the  battle  of  Waterloo  ?  This 
has  not  yet  been  shown."  Again,  in  our  hospitals  do  we 
observe  phenomena  which  were  not  presented  in  similai* 
cases  many  years  ago  i  Or  do  we  find  that  the  phenomena 
described  by  Hippocrates  are  no  longer  seen  under  the  same 
pathological  states  i  If  a  person  expose  the  feet  to  damp  and 
cold,  antl  get  an  inflammation  of  the  lungs,  do  we  not  observe 
hepatization  now  as  formerly  ?  And  if  it  be  admitted  that  we 
do  have  the  same  hepatization  now  as  in  the  days  of  Cullen, 
is  it  not  removed  in  the  same  way  that  it  formerly  was  I  Xow, 
then,  if  these  changes  cannot  be  shown,  as  they  cannot  be, 
then  I  ask  for  the  proof  that  the  essential  uatm-e  of  inflamma- 
tion has  changed  within  the  last  thirty  years,  so  as  to  require 
the  complete  revolution  in  practice  which  we  observe,  both  in 
this  country  and  in  Em-ope,  and  which  is  no  longer  denied  by 
any  physician  of  respectable  intelligence. 


PRACTICE    OF   MEDICINE.  31 

The  only  possible  answer  which  can  he  made  is  that  which 
has  been  proposed  by  Dr.  Alison :  that  the  symptoms  of  pneu- 
monia given  by  CuUen  differ  from  those  given  by  Grissolle.  and 
other  recent  writers.  This  answer  is  exceedingly  imperfect, 
since  it  has  only  been  since  the  days  of  Cullen  that  physicians 
have  learned  that  the  symptoms  of  pneumonia  given  by  Cullen 
do  not  necessarily  arise  from  pneumonia — that  they  may  exist 
where  there  is  no  inflammation  of  the  lungs — and  that  pneu- 
monia may  exist  where  none  of  these  symptoms  are  present. 
The  stethescope,  together  with  the  researches  of  morbid  anato- 
mists, has  revealed  symptoms  not  known  to  the  older  writers, 
and  hence  the  change  of  given  symptoms.  It  is  for  this  rea- 
son that  we  can  draw  no  inferences  as  to  the  changes  of  the 
types,  or  even  phases,  of  disease  now,  as  compared  with  the 
same  diseases  in  the  time  of  Cullen  and  Gregory.  The  symp- 
toms of  pneumonia  then  constituted  the  disease,  in  their  esti- 
mation ;  but  now  we  seek  for  the  lesion  which  is  the  basis  of 
the  disease,  and  hence,  too,  we  now  find  actual  pneumonia 
present  where  Cullen  never  would  have  suspected  it ;  or, 
again,  what  he  would  have  pronounced  a  pneumonia,  we 
now  know,  often,  not  to  be  really  such. 

In  consequence  of  refusing  to  recognize  these  facts,  Dr.  Al- 
ison says,  inasmuch  as  the  fever  which  accompanied  Cullen's 
pneumonia  was  inflammatory,  and  that  which  now  accompa- 
nies pneumonia  is  typhoid,  that,  therefore,  the  pneumonia  of 
this  day  does  not  bear  blood-letting  as  did  the  pneumonia  of 
Cullen.  To  this  Bennet  replies,  and  my  own  experience  con- 
firms  his  statement,  that,  during  seven  years'  experience  as 
Physician  to  the  Royal  Dispensary  of  Edinburgh,  he  has  had 
abundant  opportunity,  and  has  satisfied  himself  that  a  true 
pneumonia  is  the  same  everywhere,  and  under  all  circum- 
stances. When  it  attacks  old,  debilitated  patients  we  may 
expect  it  to  be  typhoid ;  and  when  it  fastens  on  young,  vigor- 
ous persons,  it  will  be  inflammatory ;  and  this,  no  doubt,  has 
always  been  the  case. 

As  it  is  generally  admitted  that  fevers  do  present  changes  in 
type,  or  rather  in  phase,  and  Dr.  Alison  contends  that,  there- 
fore, inflammation  may  also  change,  Bennet  has  shown,  in 
the  paper  to  which  reference  has  already  been  made,  that  es- 
sential fevers  may  be  either  typhus,  typhoid  or  ephemeral ; 
but  this  variety  of  phases  depends  altogether  on  the  vari- 
ations of  intensity  of  the  exciting  causes.  What  the  na- 
ture of  these  variations  is,  is  not  clearly  established  ;  yet 
from  observations  in  this  country,  and  irom  the  observa- 
tions of  scrutinous  observers  in  Europe,  I  think  that  these 
variations  depend  on  diet,  locality,  climate,  meteorologic 
influence,  etc.  But  the  causes  of  inflammation  are  the  same 
everywhere,  and  the  only  variation  arises  from  the  constitu- 


32  ECLECTIC    TREATISE    ON    THE 

tional  stamina,  and  the  intensity  of  the  cause.  It  is  assumed  by 
the  advocates  of  the  change  theory  that  the  pulse,  too,  has 
undergone  a  change,  and  is  not  now  lull  and  bounding,  as  it 
formerly  was — to  which  Bennet  replies :  "  For  my  own  part,  I 
have  earnestly  sought  for,  but  cannot  discover  a  shadow  of 
evidence  for  such  a  belief.  Moreover,  I  have  a  most  lively 
remembrance  of  all  the  facts  and  circumstances  connected  with 
the  bleeding  of  many  patients  by  myself,  twenty-eight  years 
ago,  when  I  first  commenced  the  study  of  medicine,  as  well  as 
of  such  as  took  place  in  the  Royal  Infirmary  of  Edinburgh, 
when  I  was  a  student  in  the  University  in  1833  ;  and  my  im- 
pression is  that  not  the  slightest  difiereuce  exists  between  the 
character  of  tlie  pulse  now,  and  what  it  was  then." 

In  British  India,  in  the  United  States,  in  France,  in  Ger- 
many, the  practice  of  blood-letting  is  as  little  practiced  as  in 
Great  Britain,  and  it  would  be  fair  to  infer  that  where  these 
changes  in  practice  have  taken  place  that,  on  the  theory  of  Dr. 
Alison,  the  type  of  disease  has  changed.  But  in  Italy,  and 
in  the  Charity  Hospital  in  Paris,  physicians  bleed  now  with  as 
much  heroism  as  at  any  previous  time,  and  we  must  necessa- 
rily, on  Alison's  theory,  conclude  that  diseases  have  changed 
in  India,  America,  Germany  and  Great  Britain,  but  that  they 
have  not  so  chauged^n  Italy  ;  or  that,  while  they  have  changed 
everywhere  else  in  France,  they  have  not  changed,  in  Bouil- 
lard's  judgment,  at  La  Charite  Hospital.  Such  a  belief  would 
be  unworthy  of  Dr.  Alison,  and  many  of  those  who  have  un- 
dertaken to  defend  him  against  Dr.  Bennet.  These  facts  go 
very  far,  in  my  mind,  toward  establishing  the  second  proposi- 
tion of  Dr.  Bennet — that  inflammation  in  a  part  is  the  same 
now  as  it  ever  has  been,  save  those  variations  of  habit,  diet,  etc., 
which  have  been  already  pointed  out. 

The  profession  has  so  much  at  stake  in  this  question  of 
change,  that  I  consider  it  my  duty  to  establish  one  or  the  other 
proposition — change  or  sameness — at  the  very  outset  of  this 
treatise.  This  is  the  first  attempt,  in  America,  to  present  the 
subject  in  detail,  and  if  I  shall  settle  the  question  definitely,  I 
shall  have  attained  a  point  from  which  every  practitioner  can 
judge  the  rationality  of  the  numerous  sectarian  theories  that 
now  divide  medical  opinion.  The  ready  adoption  of  old  theo- 
ries, merely  for  antiquity's  sake,  has  been  prolific  of  very 
much  error  in  medical  practice. 

It  has  been  supposed  that  almost  every  disease  depended 
upon  the  presence  of  morbid  materials  in  the  blood,  and  bleed- 
ings have  been  practiced  to  remove  these  morbid  materials. 
Again,  blood-letting  has  been  practiced  to  diminish  the  flow 
of  blood  to  a  particular  paii;,  where  the  seat  of  disease  was 
supposed  to  be.  That  there  was  an  accumulation  of  blood  in 
the  part  so  diseased,  and  that  general  blood-letting  would  re- 


PKACnCE   OF  MEDICINE.  33 

lieve  the  part  of  such  accumulation,  and  fi'om  all  other  facts,  it 
has  been  determined  that  the  pulse  was  the  index  as  to  the 
quantity  of  blood  that  ought  to  be  drawn. 

But  before  adopting  these  rules  of  practice  we  ought  to  have 
first  determined  whether  these  rules  really  had  any  founda- 
tion— whether  they  were  really  supported  by  facts.  If,  in  gen- 
eral blood-letting,  it  can  be  shown  that  the  materies  morbi  are 
alone  removed,  then  that  fact  would  very  strongly  point  to  the 
philosophy  of  venesection.  The  great  difficulty  of  the  older 
physicians  consisted  in  confounding  fever  and  inflammation. 
The  old  idea  was  that  the  circulating  fluid  was  thrown  into  a 
sort  of  ebullition,  that  worked  off  the  morbid  materials  ;  that  if 
this  morbid  matter  was  allowed  to  remain  in  the  blood,  it 
finally  fell  on  some  internal  organ,  and  produced  inflamma- 
tion. It  was  thought  that  the  blood  was  diseased  first,  and 
that  local  lesions  supervened  as  a  consequence.  These  views 
are  found  in  the  writings  of  the  advocates  of  blood-letting, 
from  the  days  of  Hippocrates  to  those  of  Sydenham ;  from 
him  to  Cullen,  and  even  down  to  the  present  day. 

While  it  will  be  generally  admitted  that  the  system  is  more 
or  less  influenced  by  the  most  insignificant  local  disease — for 
nutrition  in  every  part  depends  on  the  blood,  and  whatever 
modifies  the  nutrition  of  any  part,  either  to  stimulate  or  retard 
the  process,  will,  therefore,  to  that  extent  alter  both  the  quan- 
tity and  the  quality  of  the  circulating  fluid — yet  it  seems  to 
have  been  forgotten  that  each  disease  is  itself  the  means  for  ex- 
pelling this  morbid  material.  Dr.  Addison  has  pointed  out 
this  in  distinctive  eruptive  fevers,  as  small  pox,  where  the 
small  abscesses  in  the  skin  eliminate  the  poison  which  for- 
merly existed  in  the  blood :  and  it  is  by  favoring  that  elimina- 
tion that  we  may  expect  to  effect  a  cure.  Experience  shows 
that  we  cannot  effect  the  same  end  by  general  blood-letting. 
So  true  is  this  that  almost  every  well  informed  physician  now 
admits  the  fact,  and  modifies  his  practice  to  the  accommoda- 
tion of  experience  rather  than  of  the  theory. 

The  same  is  evidently  true  of  inflammation,  when,  in  addi- 
tion to  the  local  changes  in  a  part,  there  must  necessarily  be 
more  or  less  disturbance  of  the  general  functions  of  secretion 
and  excretion.  In  all  these  changes  the  blood  is  materially 
modified.  The  secretion  which  is  suppressed  is,  of  com*se,  ac- 
cumulated in  the  blood,  along  with  an  excess  of  fibrin.  The 
investigations  of  Andrei,  Rodier,  and  others  (in  fact,  no  one 
questions  the  statement),  have  shown  that  venesection  greatly  de- 
teriorates the  blood,  impoverishing  it  in  its  red  corpuscles,  and 
enriching  it  in  water ;  but  it  is  also  a  fact  that  the  proportion 
of  fibrin  is  not  so  affected.  That  there  are  materies  morbi  in 
the  blood  is  not  denied,  but  these  can  only  be  removed  by  ceU 
development,  and  that  pecuKar  vital  chemistry  which  governs 


34:  ECLECTIC    TREATISE    ON    THE 

the  character  and  movements  of  the  blood.  Blood-letting  re- 
tards both  cell  growth  and  chemical  elaboration  in  the  animal 
economy,  and  for  this,  if  for  no  other  reason,  it  ought  not  to  be 
practiced. 

Again,  it  may  be  inquired,  whether  a  connect  understanding 
of  general  pathology  justifies  us  in  retarding  the  flow  of  blood 
to  an  inflamed  part.  The  increased  flow  of  blood  to  an  inflamed 
part,  and  the  increased  throbbing,  are  not  the  cause,  but  the 
result  of  the  inflammation.  Dr.  Williams,  in  his  Principles 
of  Medicine,  treats  the  "  determination  "  of  blood  to  a  part 
as  a  cause  of  disease  ;  but  hardly  any  well  informed  physician 
would  now  be  willing  to  stake  his  professional  reputation  on 
such  an  apparent  error.  Dr.  Bennet  says :  "In  all  cases,  the 
primary  stimulus  producing  inflammation  is  applied  to  the 
vessels  of  the  part,  either  directly  ( as  ti'om  injuries  or  irri- 
tants), or  indirectly,  that  is,  by  reflex  action  (  as  in  the  case  of 
internal  inflammations,  following  exposure  to  cold,  etc.)  ;  and, 
in  consequence,  that  is  to  say  as  a  result  of  the  local  change 
in  the  part  thereby  occasioned,  there  follows  the  throbbing  of 
the  neighboring  arteries."  And  Prof.  Bennet  then  proceeds  to 
illustrate  this  position  by  calling  attention  to  the  circumstances 
of  a  thorn  driven  into  the  finger.  Here  the  irritating  body 
acts  on  the  nerves  and  blood-vessels  of  the  part ;  stoppage  of 
blood  and  exudation  follow,  and  lastly  we  have  the  throbbing 
of  the  artery  in  the  finger,  l^ow,  then,  the  throbbing  is  the  ev- 
idence of  the  so-called  determination,  the  cause  of  which  has 
been  the  injuries  inflicted  on  the  nerves  and  blood-vessels  of  the 
part  by  the  thorn.  The  throbbing  is  a  result  of  the  inflamma- 
tion, and  by  no  means  a  cause  of  it.  And  Dr.  Bennet  asks  the 
significant  question,  "  whether  would  it  be  reasonable  to  treat 
such  an  inflammation  by  opening  the  artery,  or  by  favoring 
the  transformation  of  the  exudation  thrown  out  into  pus,  where- 
by the  irritating  cause  and  its  results  are  both  got  rid  of? " 
Every  physician  who  has  had  any  experience  knows  that  the 
latter  course  would  constitute  the  proper  treatment,  and  that 
the  wounding  of  an  artery  under  such  circumstances  would  be 
the  most  unpardonable  mal-practice.  Dr.  Addison,  in  his  cell 
therapeutics,  points  out  very  clearly  why  there  should  be  an 
increased  flow  of  blood  to  a  part  that  is  inflamed.  Inflam- 
mation having  been  established,  it  is  necessary,  in  order  to 
break  up  the  exudation,  that  there  should  be  an  increased  growth 
by  cell  formation  ;  there  must  be  sent  hither  an  increased  flow 
of  blood,  whereby  the  whole  shall  be  eliminated  from  the 
economy,  either  by  external  discharge,  or  by  being  taken  into 
the  general  circulation,  and  then  expelled  by  the  natm-al  emunc- 
tories.  It  is  a  common  law,  and  universally  admitted  in  the 
science  of  physiology,  that,  where  there  is  an  increased  growth 
there  is    an  increased   flow  of  blood — a  good  example    of 


PRACnCE   OF  MEDICINE,  35 

which  is  seen  at  the  period  of  heat  in  animals,  when  an 
increased  flow  of  blood  is  required  to  ripen  the  graafian 
vesicles.  So,  too,  in  the  scalp  of  the  stag  during  the  de- 
velopment of  the  antlers ;  in  the  female  mammae  when 
milk  is  first  secreted  ;  in  the  gums  of  an  infant  dm*ing  den- 
tition ;  in  the  case  of  tumors  within  or  on  the  body ;  and  in 
the  ascent  of  an  increased  flow  of  sap  in  the  plant,  when  its 
foliage  is  being  developed,  in  the  spring  of  the  year.  In  all 
these  instances  the  increased  flow  is  drawn  to  the  part  in  con- 
sequence of  the  increased  production  of  cells,  which  necessa- 
rily reqmre  an  unusual  amount  of  blastema.  So  says  Dr. 
Bennet,  in  inflammation,  an  exudation  having  been  poured 
out,  wliich  has  to  be  transformed  by  a  process  of  cell  growth, 
in  order  that  it  may  be  removed,  or  rendered  subservient  to  the 
wants  of  the  economy,  it  is  absolutely  imperative  that  the  part 
in  which. these  nutritive  changes  go  on  should  receive  more 
blood,  to  enable  it  to  accomplish  them.  This,  then,  is  why 
Nature,  in  her  wisdom,  directs  an  increased  flow  of  blood  to  an 
inflamed  part,  and  when  it  is  so  understood,  no  rational  physi- 
cian will  entertain  for  a  moment  a  wish  to  arrest  that  flow. 
Yet  the  great  mass  of  the  profession  has,  hitherto,  regarded 
this  increased  flow  as  positively  injurious,  and  they  have  rack- 
ed their  inventive  powers  for  means  to  arrest  this  sanitary  cur- 
rent. Blood-letting  has  been,  as  Sydenham  says,  their  "sheet 
anchor ;  "  but  now  all  can  see  on  what  false  pathological  data. 

This  is  the  docti'ine  for  which  the  eclectic  branch  of  the  med- 
ical profession  has  so  manfully  battled  during  the  past  quarter 
of  a  century,  and  which  Dr.  Bennet  now  brings  forward  in  Eu- 
rope as  a  thing  quite  new.  I  care  not  who  has  the  credit  there- 
for, but  I  beg  to  call  attention  to  the  fact  that  the  natural  re- 
searches of  physicians,  when  understaudiugly  prosecuted,  lead 
spontaneously  to  the  same  conclusions.  Dr.  Bennet  has  put  a 
flea  in  the  ear  of  the  European  profession,  and  no  human  power 
can  ever  crush  the  bold  thought  which  he  has  uttered. 

It  will  be  borne  in  mind  that  I  do  not  contend  that  all  who 
have  claimed  to  be  eclectic  have  built  their  practice  on  these 
views.  Far  from  it ;  for  there  are  many  in  this  branch  of  the 
profession,  as  well  as  in  other  branches,  who  will  sooner  follow 
the  practice  of  others  on  the  basis  of  general  results,  than  take 
the  trouble  to  iuqiiire  why  their  practice  difiers  fi'om  the  rest  of 
the  profession.  Nay,  more ;  we  have  large  tomes  on  the  prac- 
tice of  medicine,  eclectically,  by  men  who  are  shamefully  ig- 
norant of  the  first  elements  of  true  eclectic  practice.  The  lead- 
ing eclectic  school  in  the  United  States  has  often  endeavored 
to  shake  off"  such,  and,  to  a  very  great  extent,  has  succeeded ; 
G.  g.,  the  large  number  expelled  by  the  Board  of  Trustees  of 
the  Eclectic  Medical  Institute  in  1856.  Rather  than  admit 
their  superficialities,  they  actually  organized  a  school  in  order 


36  ECLECTIC    TKEATISE    ON    THE 

to  maintain  their  respectability  in  the  profession  ;  bnt  the  ruse 
was  a  failure,  and  in  less  than  two  years  only  one  or  three  remain 
in  these  parts.  It  has  been  Irom  the  unwise  course  of  such  per- 
sons that  the  general  profession  in  this  country  has  been  so  prone 
to  keep  aloof  from  those  whom  they  knew  to  be  physicians  of 
the  very  highest  attainments.  But,  since  there  was  never  yet 
a  medical,  religious  or  political  organization,  clear  of  these 
fanguous  attachments,  it  is  to  be  hoped  that  this  branch  of  the 
medical  profession  will  not  materially  suffer  thereby. 

The  next  important  question  in  the  discussion  of  these  pro- 
positions is,  does  general  blood-letting  diminish  the  amount 
of  blood  in  the  part  which  is  laboring  under  an  inflammation  ? 
It  would  be  absm'd  to  deny  that  general  blood-letting  in  the 
ti*eatment  of  inflammation  has  long  been  practiced  with  this 
intention.  It  has  been  believed  that  the  part  ought  to  be  freed 
from  sanguineous  engorgement,  and  that  blood-letting  would 
accomplish  that  end.  Admitting  that  it  were  desirable  to 
diminish  the  quantity  of  blood  in  the  part,  it  certainly  cannot 
be  shown  that  blood-letting  will  do  this  directly.  It  has  never 
yet  been  shown  that  draining  the  general  system  will  relieve 
an  engorged  part.  The  practice  and  principle  are  founded  on 
the  idea  that  the  blood  has  a  peculiar  afiinity  for  the  inflamed 
part,  and  not  that  it  is  merely  arrested.  The  blood  corpuscles 
in  such  a  part  are  closely  crowded  in  the  enlarged  vessels,  and 
the  vascular  tissue  is  thus  distended,  which  phenomena  are  in 
no  way  afi'ected  by  the  flow  of  the  arterial  current,  even  though 
in  close  proximity.  Now,  the  removal  of  the  exudation  is 
admitted  to  be  the  great  aim  of  ti'eatment;  and  I  ask  how, 
when  this  exudation  is  outside  of  the  vessels,  can  general  blood- 
letting alter  this  state  of  afiairs  ?  l^o  local  or  ordinary  general 
blood-lettings  can  directly  diminish  the  quantity  of  blood  in  a 
part,  and  even  when  large  quantities  are  abstracted  the  effect 
is  indirect,  and  could  be  much  more  easily  obtained,  if  it  was 
actually  necessary,  by  bandages  on  the  thighs  and  arms, 
which,  by  compressing  the  veins  and  not  the  arteries,  would 
enable  the  latter  to  pump  the  veins  of  the  limbs  lull,  and  thus 
diminish  the  general  amount  of  circulating  fluid.  This  plan 
has  been  proposed,  but  there  is  as  little  indication  for  that 
practice  as  there  is  for  blood-letting.  The  phenomena  of 
syncope  can  be  thus  much  more  readily  induced  than  by  vene- 
section, but  nothing  more  is  gained  save  that  the  system  is  not 
so  impoverished.  But  it  must  be  borne  in  mind  that  if  the 
blood  be  thus  dammed  up  for  any  considerable  time,  that 
it  will  be  unfit  for  circulation  in  consequence  of  the  very  large 
accumulation  of  matter  in  its  descending  metamorphosis ;  a 
fact  apparent  enough  when  we  remember  that  lor  every  beat  of 
the  pulse  no  less  than  twenty  millions  of  blood-cells  are 
destroyed,  which  must  be  speedily  eliminated  or  general  irri- 


PKACnCE    OP   MEDICmE.  37 

tation  and  fever  supervene.  It  has  been  already  seen  that 
the  exudation  can  only  be  removed  by  new  cell  growth,  and 
that  this  depends  on  an  increased  flow  of  blood;  therefore 
blood-letting,  by  arresting  this  increased  flow,  would  retard  the 
removal  of  the  exudation,  and  thus  prolong  the  eflbrt  of 
the  system  to  recuperate. 

Local  blood-letting  is  altogether  inexplicable,  and  on  no 
theory  can  it  be  shown  to  effect  any  real  good.  If  a  person  is 
attacked  with  pneumonia,  and  leeches  are  applied  to  the  integ- 
uments, how  does  this  affect  the  changes  in  the  vessels  supplied 
directly  from  the  aorta,  since  the  integuments  are  supplied  by 
vessels  derived  from  the  mammary  arteries  ?  There  is  no 
direct  anastomosis  between  them  as  has  been  demonstrated  by 
Struthens  and  other  observant  anatomists ;  yet  it  is  not  denied 
that  local  blood-letting  often  removes  the  pain  incident  to  such 
inflamed  parts,  and  the  rationale  thereof  is  demanded.  I  ask 
if  the  good  effects  do  not  depend  upon  the  reflex  influence  of 
counter-irritation,  or  from  the  soothing  influence  of  the  warm 
fomentations  which  are  at  the  same  time  applied?  It  is  a 
known  fact  that  dry  cupping  is  often  as  efiicient  as  local  bleed- 
ing, and  if  the  explanation  is  other  than  that  already  given, 
why  is  this  so  ?  No  reasoning  and  no  experiments  have  yet 
demonstrated  that  local  blood-letting  can  diminish  the  quantity 
of  blood  in  an  inflamed  part. 

Everywhere,  and  for  nearly  all  time,  the  advocate  of  bleed- 
ing has  rushed  to  the  wrist  to  examine  the  state  of  the  pulse, 
without,  in  all  probability,  ever  once  inquiring  seriously  whether 
a  strong  pulse  necessarily  implies  a  necessity  for  the  abstrac- 
tion of  blood.  Or,  as  Dr.  i3ennet  says,  "  because  natm-e 
accelerates  and  strengthens  the  pulse,  it  has  been  thought  that 
art  ought  to  interfere  and  diminish  its  force  and  frequency." 
It  has  been  already  shown  that  nature  rids  herself  by  the  for- 
mation of  new  cell  growth  to  transform  the  exudation  of 
inflammation,  and  finally  eliminate  it  from  the  system,  and  for 
this  reason  she  raises  the  force  and  frequency  of  the  pulse. 
The  object  of  interference  is  to  lower  the  pulse — to  diminish  the 
force  of  the  circulation — to  retard  the  flow  of  blood  to  the 
part,  and  therefore  the  effect  is  to  prolong  nature's  efl'ort  to 
secm-e  the  necessary  transformation.  The  inconsistency  of  this 
practice  is  readily  seen  when  the  practitioner,  finding  the  pulse 
hard  and  full  in  pneumonia,  at  once  bleeds  the  patient  until  it 
becomes  weak,  and  then  he  immediately  sets  about  strength- 
ening it  by  the  administration  of  tonics  and  stimulants.  This 
contrary  practice  is  proof  of  the  error  in  one  or  the  other  case — 
either  that  the  man's  blood  ought  to  have  been  let  alone,  or 
else,  when  drawn,  he  ought  to  have  been  allowed  to  remain 
weak.  If  it  was  right  to  weaken  his  pulse,  why  strengthen  it 
after  that  end  has  been  attained  ?     Ih*.  Benuet  is  so  clear  on 


38  ECLECTIC    TREATISE    ON    THE 

this  point  that  I  quote  his  language :  "In  short,  we  argue  that 
the  phenomena  of  fever  and  excitability  following  inflamma- 
tion, have  been  wrongly  interpreted,  and  that  danger  is  to  be 
apprehended  from  them — not  directly,  but  from  the  subsequent 
exhaustion  which  all  great  exertions  of  the  animal  economy 
produce.  In  themselves,  these  are  sanitary,  and  indicate  the 
struggle  which  the  economy  is  engaged  in  when  attempting  to 
get  rid  of  the  diseased  process ;  and  we  only  diminish  the 
chances  of  that  struggle  terminating  favorably  by  lessening 
the  vital  powers  at  such  a  critical  juncture." 

It  is,  however,  contended  that  blood-letting  relieves  pain, 
and  therefore  ought  to  be  practiced.  That  it  does  relieve  pain 
is  a  tact,  but  it  must  be  admitted  that  the  duty  of  the  physician 
is  to  cure  and  relieve.  He  tries  first  to  cure,  and  if  his 
attempts  are  abortive,  then  he  tries  to  relieve.  The  principle 
of  cure  and  the  principle  of  relief  may  be,  and  often  are, 
incompatible ;  in  which  case  the  principle  of  relief  should  be 
sacrificed  to  the  principle  of  cure,  as  when  that  has  been 
accomplished  the  relief  will  be  spontaneous,  but  the  relief 
does  not  imply  a  spontaneous  cure  by  any  means. 

Blood-letting  seems  to  be  advisable  only  in  the  case  of 
aneurisms,  yet,  generally,  I  doubt  whether  even  then  it  pro- 
longs the  patients  life  a  single  day.  It  is  true  that  the  expected 
relief  will  be  obtained  by  a  small  abstraction ;  yet,  when  fre- 
quently practiced,  as  it  must  be,  the  system  is  so  weakened 
that,  in  all  probability,  the  patient  sinks  under  the  treatment 
sooner  than  he  would  irom  the  disease.  But  it  is  not  for  the  sake 
of  palliation  that  blood-letting  has  been  heretofore  practiced, 
and  even  when  it  is  so  practiced,  the  philosophy  thereof  has 
not  been  commonly  understood.  And  from  what  has  here 
been  s^id,  it  is  evident  that  the  principles  on  which  it  has  been 
heretofore  practiced  are  erroneous,  which  is  the  position  taken 
by  Dr.  Bennet  in  his  third  proposition.  If  the  facts  adduced 
can  be  refuted,  every  physician  ought  to  feel  it  a  duty  to  come 
forward  with  the  arguments  and  data  of  reftitation.  No  such 
attempt  can  be  successful,  however,  in  my  opinion,  since  truth 
cannot  be  rectified. 

Dr.  Bennet's  fourth  proposition  is,  that  an  inflammation 
once  established  cannot  be  cut  short,  and  that  the  only  end  of 
judicious  medical  practice  is  to  conduct  it  to  a  favorable  ter- 
mination. This  is  a  bold  proposition,  and  if  clearly  estab- 
lished, must  weigh  very  heavily  agunst  the  antiphlogistic 
treatment  of  inflammations.  By  a  little  examination  of  the 
older  aulhorities,  we  shall  find  that  they  held  it  to  be  the  duty 
of  the  practitioner  to  interfere  in  the  treatment  of  many  dis- 
eases which  are  now  allowed  to  run  their  natural  course,  as 
typhus,  small  pox,  etc.  Interference  in  the  treatment  of  these 
complaints  was  attended  with  such  fatal  consequences,  that 


PRACTICE   OF   MEDICINE.  39 

physicians  were  compelled  to  disregard  authority  and  appeal 
to  experience  for  principles  of  procedure.  In  this  way  it  has 
been  agreed  on  all  hands  that  the  duty  of  physicians  in  the 
treatment  of  these  diseases  and  many  others,  is  to  prevent 
their  attachment  to  the  system  if  possible ;  and,  if  this  fails, 
then  to  conduct  them  to  a  favorable  termination.  Internal 
inflammations  run  through  a  definite  course  as  well  as  those 
complaints,  and  if  so,  then  I  can  see  no  reason  why  the  same 
principles  of  practice  should  not  pertain  in  this  as  in  that  case. 
To  comprehend  the  fact  of  definiteness  in  the  progress  of  an 
internal  inflammation,  we  have  only  to  examine  the  phenomena. 
By  closely  ol  serving  the  com'se  of  an  inflammation,  we  notice 
that  it  terminates  in  one  of  two  ways,  firstj  in  the  language  of 
Bennet,  by  vital  changes  of  growth  of  dilfereut  kinds  in  the 
exudation,  constituting  what  has  been  heretofore  called  sup- 
puration, adhesion,  granulation,  cicatrization,  the  healing  pro- 
cess, etc. ;  or,  secondly,  by  death  of  the  exudation,  which,  if 
rapid,  putrefies,  producing  gangrene ;  or,  if  slow,  disintegrates, 
causing  ulceration,  suppuration,  adhesion,  granulation,  etc., 
— ^really  sanative  processes.  Especially  is  this  so  in  regard 
to  suppuration,  which  ought  to  be  regarded,  as  it  really  is,  as 
a  growth  that  enables  the  coagulated  blood-plasma  and  exuda- 
tion to  be  broken  up  and  eliminated  from  the  system.  It  should, 
therefore,  be  encouraged ;  yet  it  has  hitherto  been  the  aim  of 
the  practitioner  to  check  rather  than  encourage  the  process. 
It  is  evident  that  W'hatever  weakens  the  strength  or  debilitates 
the  patient,  will  retard  the  nutritive  processes  of  development, 
and  thereby  impede  exudation.  Blood-letting  being  thus  capa- 
ble of  weakening  the  system,  is  directly  opposed  to  the  rapid 
breaking  up  of  an  inflammation ;  and  therefore  would  not  be 
emploj'ed  by  a  judicious  practitioner  well  informed  of  the 
pathology  of  inflammation. 

That  inflammation  is  a  sanative  process,  needs  only  to  be 
understood  to  be. acknowledged.  Thus,  if  a  splinter  be  thrust 
into  the  finger,  what  is  the  effort  of  nature  to  remove  the 
foreign  substance?  Inflammation,  suppuration,  etc.,  there 
being  a  regular  series  of  changes  until  the  splinter  is  finally 
expelled,  if  it  was  a  destructive  process,  nature  would  hardly 
invoke  its  aid  in  a  recuperative  way.  If  there  had  been  no 
inflammation,  there  would  have  been  no  "festering"  and  no 
expulsion  of  the  splinter.  Again,  if  a  bone  be  broken,  inflam- 
mation in  the  region  of  the  fracture  is  set  up,  an  exudation 
takes  place,  and  by  certain  vital  processes  this  exudation  is 
finally  transformed  into  bone.  If  the  surrounding  soft  tissues 
are  injured,  there  is  poured  out  an  exudation  from  the  adjoin- 
ing vessels,  which,  by  other  vital  changes,  is  finally  transformed 
into  equivalent  soft  tissues — fibrous  it  may  be,  constituting 
granulations  first,  and  cicatrization  afterward.     When  a  vio- 


40  ECLECTIC  TKEATISE  ON  THE  PRACTICE  OF  MEDICINE. 

lent  blow  has  been  received,  more  or  less  exudation  occurs, 
and  is  infiltrated  among  the  bruised  tissueSv  which,  by  cell 
growth,  is  transformed  into  pus  ;  which,  ii  an  opening  be 
made,  is  got  rid  of  externally ;  or  else,  by  the  disintegration 
of  the  cells,  is  absorbed,  and  is  finally  eliminated  from  the 
economy.  In  the  one  case — that  is,  where  the  pus  is  absorbed 
as  fast  as  it  forms — the  tumor  is  said  to  be  discussed ;  but  if 
not,  it  collects  in  a  body,  a  fluid  mass,  and  then  constitutes  an 
abcess.  Now,  if  these  processes  are  recuperative  and  essen* 
tial,  how  can  blood-letting  favor  them,  when  it  is  universally 
admitted  that  the  general  system  is  weakened  by  the  practice  ? 
When  called  to  treat  a  patient  who  has  suffered  a  fracture,  a 
bruise  or  an  injury,  if  we  find  the  constitution  strong  and  vig- 
orous, our  prognosis  must  be,  and  always  is,  favorable ;  but  if 
the  patient  is  scrofulous  or  very  weak,  we  know  that  recovery 
will  either  be  slow  or  impossible,  and  hence,  the  unfavorable 
prognosis  of  the  case.  Yet,  while  this  principle  is  recognized 
and  acted  on  in  practice,  we  find  numerous  respectable  phy- 
sicians contending  for  a  theory  that  would  lead  to  directly 
contrary  results.  This  is  one  of  many  medical  inconsis- 
tencies. 

In  the  case  of  internal  inflammations,  the  processes  are 
identically  the  same.  Suppose  the  part  so  attacked  with  in- 
flammation to  be  the  lungs  or  pericardium,  do  we  not  have  the 
exudation  converted  into  pus  cells  and  absorbed,  or  into  fibrous 
texture  forming  adhesions?  No  pathological  anatomist  will 
deny  this  statement ;  yet,  instead  of  witnessing  the  physician 
treating  an  internal  inflammation  as  the  surgeon  does  an 
external  one,  he  attacks  the  general  symptoms,  which  are  but 
the  effects  of  a  lesion.  In  other  words,  he  endeavors  to  gag 
nature  when  she  tries  to  proclaim  her  ailment  by  certain 
symptoms.  He  combats  their  appearance,  and  endeavors  to 
drive  them  back  without  once  striking  at  the  cause  which 
produces  them.  In  the  case  of  a  fracture  we  have  febrile 
symptoms  as  a  result — the  pulse  is  increased,  etc. ;  yet  would 
any  well  informed  surgeon  venture  to  afiirm  that  callus  would 
more  readily  form  by  blood-letting  and  antiphlogistic  treat- 
ment? Experience  has  taught  the  sm'geon  otherwise;  and  as 
internal  inflammation  is  the  same,  why  should  the  physician  not 
profit  by  the  same  experience  ? 


CHAPTER   m. 


In  the  case  of  pneumonia,  we  have  what  is  called  hepatiza- 
tion of  the  lungs,  which  is  only  the  completion  of  the  changes 
which  serve  to  make  up  a  true  pneumonia.  "The  exudation 
is  infiltrated,"  says  Dr.  Bennett,  "  into  the  air  vesicles  and  mi- 
nute bronchi,  and  between  the  fibers,  blood-vessels  and  nerves 
of  the  parenchyma,  imprisoning  the  whole  in  a  soft  mass, 
which  coagulates  and  renders  the  spongy  texture  of  the  lung 
more  dense."  This  ejffectually  prevents  the  entrance  of  the 
air,  arrests  the  circulation,  and  compresses  the  nerves.  Na- 
ture, in  order  to  re-establish  her  functions,  labors  to  re-convert 
the  solid  exudation  into  a  fluid,  that  it  may  be  evacuated  irom 
the  bronchi,  or  re-absorbed  into  the  circulation,  and  finally  be 
thus  expelled  from  the  system.  This  is  accomplished  by  cell 
growth  entirely,  in  the  formation  of  pus.  Having  been  thus 
reduced  to  pus,  it  is  taken  into  the  circulation,  where  it  is  once 
more  metamorphosed — changed  into  urate  of  ammonia,  or 
an  acid,  etc. — and  in  its  further  changes  passes  into  urea  and 
carbonic  acid,  and  a  number  of  other  chemical  combinations. 
If  the  amount  of  oxygen  taken  in  is  insufficient  to  eflTect  these 
final  changes,  it  appears  in  the  urine  as  uric  acid  and  fibrin. 
Liebig  gave  us  the  first  clue  to  these  chemical  changes  which 
occur  in  the  system  while  the  pus  is  being  prepared  for  elim- 
ination from  the  economy. 

In  pleurisy,  pericarditis,  etc.,  the  changes  are  somewhat 
modified,  but  the  same  great  principles  apply  in  the  one,  as  in 
3 


48  ECLECTIC   TEEATISE    ON    THE 

the  other  case,  and  the  final  results  are  identically  the  same. 
In  eveiy  instance  we  find  an  increased  flow  of  blood,  and  a 
heightened  cell  growth.  So  true  is  this,  that  in  pericarditis, 
where  there  are  no  cells  to  bring  in  the  increased  flow  of 
blood,  the  J  are  formed  especially  for  the  occasion.  Trans- 
formation is  the  great  object,  and  as  this  depends  on  the  in- 
creased flow  of  blood,  in  what  way  can  yenesection  proTe  ben- 
eficial, when  it  is  admitted  to  weaken  the  general  system? 
Having  satisfactorily  disposed  of  these  propositions,  and 
answered  the  objections  thereto,  I  next  proceed  to  canvass  the 
fifth  proposition  of  Dr.  Bennett,  which  appeals  to  facts  and 
experience  to  determine  whether  the  principles  already  ad- 
vanced are  sustained  or  not ;  and  here  let  me  say,  every  prac- 
titioner into  whose  hands  this  may  come,  ought  to  ransack  his 
own  memory,  and  thoroughly  scrutinize  the  subject  so  as  to 
come  to  a  rational  conclusion.  Twenty  years  ago,  the  advo- 
cates of  blood-letting  selected  pneumonia  as  that  disease  which 
particularly  demanded  the  assistance  of  the  lancet ;  hence, 
since,  also  it  is  so  held  up  even  to  the  present  day,  pneumonia 
should  now  be  selected  as  that  disease  which  should  be,  in  its 
treatment,  the  basis  of  the  facts  to  be  adduced.  But  before 
the  value  of  any  practice  can  be  determined,  it  is  necessary  to 
learn  what  is  the  natural  duration  of  the  disease.  In  the 
homoeopathic  hospital  of  Vienna,  where,  though  the  patient 
takes  certain  little  pellets — perfectly  inert  so  far  as  medicinal 
action  is  concerned —  the  patients  were  cured,  if  at  all,  by  na- 
ture. Dr.  Balfour  watched  closely  the  progress  of  the  disease, 
and  any  facts  derived  from  that  quarter  will  be  of  great  value 
to  us,  as  studies  of  the  disease  when  left  entirely  to  the  opera- 
tions of  natui'e ;  for,  as  Dr.  Bennett  well  says,  "  no  sane  man 
regards  homoeopathic  medicament  as  anything  else  than  inert," 
and,  I  may  add,  but  a  blind,  by  which  the  physician  gets  paid 
for  watching  natm-e  cure  a  disease.  There  is  also  extant  the 
recorded  experience  of  Skoda  and  Dietl  on  the  expectant  sys- 
tems, and  from  all  the  facts  thus  elicited,  it  appears  that  where 
the  attack  is  slight  the  patient  }nay  be  convalescent  on  the 
seventh  day ;  that  the  majority  of  cases  of  medium  intensity 
get  well  between  the  seventh  and  fourteenth  days,  and  very 
severe  cases  recover  between  the  fourteenth  and  twenty-first 
days.  Authors  difler,  however,  as  to  the  period  of  the  com- 
mencement and  termination  of  the  disease,  as  they  regard  this 
or  that  symptom  of  more  or  less  importance.  The  rule  most 
commonly  adopted  is  to  commence  the  count  from  the  day  of 
the  first  rigor,  and  continue  it  until  the  leading  symptoms 
have  ceased.  It  is  very  true  that  the  sequelae,  as  it  were,  of 
these  symptoms  may  last  for  some  days  after  the  patient  has 
left  his  bed.  Dr.  Bennett  is  of  the  opinion  that  when  two- 
thirds  of  one  lung  is  involved,  if  the  recovery  takes  place- 


PRACTICE   OF   MEDICINE.  43 

in  fourteen  days,  it  is  a  good  recovery,  but  not  better  than 
ought  to  be  expected  in  a  healthy  constitution.  It  must  also 
be  remembered  that  the  intensity  and  dui-ation  of  the  attack 
do  not  of  necessity  bear  relation  exclusively  to  the  amount  of 
the  lungs  involved.  We  see  one  person,  with  only  a  part  of 
one  lung  involved,  laboring  under  a  very  high  fever,  and  with 
intense  symptoms,  while  another,  with  the  whole  of  one,  or  a 
large  share  of  both  lungs  diseased,  has  very  little  constitu- 
tional disturbance.  In  the  former  case,  where  the  symptoms 
are  very  severe,  the  recovery  may  be  rapid,  and  in  the  latter, 
where  the  conditions  are  reversed,  we  shall  generally  find  the 
recovery  slow  and  tedious.  These  circumstances  are  only  re- 
cently understood.  The  disease  is  now  understood  to  be  an 
extraordinary,  but  natural  effort  of  the  system  to  rid  itself  of 
foreign  substances,  to  maintain  itself  intact  from  the  ravages 
and  effects  of  irritation  and  its  results.  The  effort  which  the 
system  is  thus  enabled  to  put  forth  will  be  proportioned  to  its 
vitality — its  health.  In  a  child  with  a  healthy  stomach,  we 
observe  the  immediate  expulsion  of  poisonous  and  improper 
substances,  while  in  the  case  of  a  weak  and  sickly  child  the 
case  is  far  otherwise.  The  fevers  of  the  one  are  intense,  and 
rapidly  run  their  course,  while  in  the  other  they  are  of  a  low 
grade,  and  slowly  linger  on  for  weeks,  and  it  may  be  months. 
The  common  belief  has  heretofore  been  that  the  symptoms 
of  pneumonia  constituted  the  disease,  and  as  these  might  be 
controlled  somewhat  by  bleeding,  it  was  thought  that  venesec- 
tion was  of  all  other  means  the  proper  treatment.  It  is  now 
known  that  the  smothering  of  the  symptoms  in  reality  only 
disenables  the  system  to  perform  its  work  of  recuperation ; 
that  the  disease,  even  after  the  suppression  of  the  symptoms, 
will  linger  on  for  weeks,  giving  rise  to  a  very  tedious  conval- 
escence, which  may  destroy  the  patient  by  general  exhaustion. 
The  relief  of  symptoms,  then,  let  it  be  understood,  is  quite 
another  thing  from  the  cure  of  the  disease,  and  we  must 
pronounce  that  the  best  practice  wherein  the  fewest  deaths 
occur,  and  under  which  the  duration  is  shortest.  Now  to  ar- 
rive at  something  like  satisfactory  conclusions,  let  us  look  at  a 
few  statistical  facts,  which  are  mostly  derived  from  the  paper 
of  Dr.  Bennett.  In  ten  years — from  1839  to  1849 — there  were 
admitted  into  the  Royal  Infirmary  of  Edinburgh  46,965  pa- 
tients, of  whom  648  were  affected  with  pneumonia,  and  under 
the  blood-letting  treatment  222  died,  while  38  only  were  re- 
lieved. Thus  over  one-third  who  entered  the  Infirmary  for 
treatment  died,  and  this  proportion  will  hold  good,  on  the 
authority  of  Dr.  Bennett,  for  any  time  since  the  commence- 
ment of  the  present  century.  The  like  astounding  mortality 
was  observed  by  M.  Louis  in  the  Hospital  of  La  Charite,  at 
Paris.     Dr.  Thornbm*n  found  in  208  case  books  of  the  Edin- 


M  ECLECTIC    TKEATISE    ON    THE 

burgh  Infirmary,  running  from  1812  to  1837,  belonging  to 
twelve  physicians,  all  of  whom  practiced  an  antiphlogistic 
treatment,  103  cases  of  pneumonia,  of  which  55  were  cured, 
41  died,  and  7  were  relieved  more  or  less.  But  to  be  still 
more  sure.  Dr.  Thornburn  carefully  read  over  these  one  hun- 
dred and  three  cases,  and  rejected  such  as  did  not  present  the 
most  unequivocal  evidence  of  pneumonia.  The  result  gave 
him  50  cases  of  pure  pneumonia,  of  which  31  were  cured  or 
relieved,  and  19  died ! 

,  M.  Louis  {Reserches  sur  les  effets  de  la  saignee)  records  107 
cases,  of  which  32  died — a  mortality  of  1  in  3^.  Of  78  cases 
occurring  at  La  Charite,  bleeding  was  performed  from  the  first 
to  the  ninth  day,  and  the  deaths  were  28  or  1  in  3j.  The 
average  duration  of  the  cases  that  recovered  was  15^  days. 
In  29  cases  observed  at  La  Pitie,  the  bleeding  was  performed 
during  the  first  four  days,  and  the  deaths  were  only  4 — or  1  in 
7i ;  but  it  was  observed  that  in  those  who  recovered  the  dura- 
tion of  the  disease  was  18:^  days.  From  the  diminished  mor- 
tality, M.  Louis  thought  that  bleeding,  if  practiced  in  pneu- 
monia, should  be  resorted  to,  if  at  all,  in  the  earlier  stages  of 
the  disease.  Rason  {Annals  de  Therapeutioa)  treated  648 
(Cases  in  the  Hospital  of  Milan,  by  large  doses  of  tartar  emetic, 
of  which  555  were  cured,  and  143  died,  or  1  in  4^ — which 
JRason  contends  is  a  result  more  favorable  than  can  be  obtained 
by  blood-letting.  M,  Grisolle  {Traite  Practique  de  la  Pneu- 
monie)  mentions  one  group  of  50  cases,  which  were  bled  in 
the  first  stages  of  the  disease  only ;  and  of  these  only  5  died, 
or  1  in  10.  Those  that  died  had  been  most  freely  bled,  each 
having  lost  in  successive  bleedings  about  4  lb.  4  oz.  of  blood. 
It  may  be  further  stated  that  these  50  cases  were  uncompli- 
cated, and  of  the  average  age  of  40  years.  Of  another  group 
"  of  182  cases,  that  were  bled  in  the  second  stage,  32  died,  or 
more  than  1  in  6."  Of  these  it  was  also  observed  that  those 
who  died  were  those  who  had  been  most  freely  bled.  These 
results  were  better  than  those  of  either  M.  Louis  or  Lsennec, 
both  of  whom  bled  more  largely  than  M.  Grisolle.  In  this 
country,  it  is  doubtful  whether  the  mortality  in  our  hospitals 
has  been  so  small  as  in  those  of  Edinburgh  and  Paris.  For 
want  of  proper  statistics,  however,  it  is  impossible  to  speak 
with  certainty.  There  are  extant  some  statistics  of  treatment 
by  diet,  with  the  results  of  which  the  above  figures  may  be 
compared,  as  throwing  very  much  light  on  this  important 
subject. 

Dr.  Balfour  records  the  dietetic  treatment  of  Skoda  in  the 
Charity  Hospital  of  Vienna.  In  this  treatment,  if  there  was 
much  pain,  a  little  opium  was  given,  and  in  the  outset  of  the 
disease  if  there  was  much  dyspncea,  venesection  w^as  practiced, 
^nd  emetics  given  if  the  expectorations  were  a  tough  mucus. 


PEACTICE   OF  MEDICINE.  45 

And  of  392  patients  thus  treated  54  died,  or  1  in  7^.  Dr. 
Dietl  treated  380  cases  of  primary  pneumonia  in, the  Charity 
Hospital  of  Yienna.  Of  these  85  were  treated  by  venesection, 
and  of  which  17  died,  showing  a  mortality  of  1  in  5.  106 
were  treated  by  large  doses  of  tartar  emetic,  of  which  22  died, 
or  1  in  5V,  and  189  by  diet  only^  of  which  only  14  died,  or  1 
in  13|-.  Thos'e  treated  by  diet  who  died,  had  their  cases  com- 
plicated, while  of  the  85  who  had  been  bled,  and  of  whom  17 
died,  7  had  no  complication  of  their  cases.  These  tigures 
show  beyond  question  that  blood-letting  and  the  administra- 
tion of  tartar  emetic  do  not  either  belong  to  a  proper  treat- 
ment of  pure  pneumonia. 

Dr.  J.  Hughes  Bennett  found  that  in  eight  years  he  had 
treated  65  cases,  of  the  average  age  of  31.  Of  these  65  cases, 
62  were  dismissed  cured,  and  3  died,  showing  a  mortality  of 
only  1  in  21f.  Dr.  Bennett  says,  "The  treatment  I  have  pur- 
sued in  pneumonia  is  founded  on  the  pathological  principles 
formerly  given,  viz.:  never  to  attempt  to  cut  short  the  disease, 
or  to  weaken  the  pulse  and  vital  powers ;  but,  on  the  contrary, 
to  further  the  necessary  changes  which  the  exudation  must 
undergo,  in  order  to  be  fully  excreted  from  the  economy.  To 
this  end,  during  the  period  of  febrile  excitement,  I  content  my- 
self with  giving  salines  in  small  doses,  with  a  view  of  dimin- 
ishing the  viscosity  of  the  blood.  As  soon  as  the  pulse 
becomes  soft,  I  order  good  beef  tea  and  nutrients  ;  and  if  there 
be  weakness,  from  eight  to  ten  ounces  of  wine  daily.  As  the 
period  of  crisis  approaches,  I  give  a  diuretic,  generally  con- 
sisting of  3ss.  of  nitric  ether,  sometimes  combined  with  mx. 
of  colchicum  wine,  three  times  daily,  to  favor  the  excretion  of 
urates.  But  if  crisis  occurs  by  sweat  or  stool,  I  take  care  not 
to  check  it  in  any  way." — Ed.  Med.  Jour.  No.  XXI.,  p.  792. 

Here,  then,  we  are  plainly  told  by  one  of  the  most  eminent 
practitioners  in  Great  Britain,  that  pneumonias  in  the  young  and 
vigorous  almost  always  get  well,  if  let  alone.  "While  the  re- 
verse of  this  is  true  under  the  antiphlogistic  treatment  of  the 
accepted  standard  books.  The  mortality  under  the  new  treat- 
ment has  been  reduced  from  1  in  3  under  the  old,  to  1  in  21f 
under  the  new.  These  facts  are  certainly  palpable  enough  to 
cause  the  advocates  of  blood-letting  to  stop  and  calmly  investi- 
gate the  pathology  under  which  such  a  practice  has  been  tol- 
erated. If  the  profession  has  been  wrong  in  this  case,  how 
could  it  be  right  in  others  ? 

Of  mercurials.  Dr.  Bennett  thus  speaks  :  "  As  to  mercurials, 
the  confident  belief  in  their  power  of  causing  absorption  of 
lympli,  by  operating  on  the  blood,  is  not  only  opposed  to  sound 
theory,  as  formerly  explained ;  but,  like  blood-letting,  is  not 
supported  by  that  experience  which  has  been  so  confidently 
appealed  to  in  their  favor."    Is   not  the  above  declaration 


46  ECLECTIC    TEEATISE    ON    THE 

identical  with  the  position  occupied  by  the  eclectic  branch  of 
the  medical  profession  in  America  ?  Yet,  notwithstanding  all 
the  abuse  heaped  on  us  for  our  heresy,  the  great  men  of  our 
profession  are  gradually  coming  to  the  same  conclusions.  Not 
only  is  this  so  in  Europe,  but  it  is  so  in  this  country.  Every 
farmer's  boy  can  tell  you  that  the  practice  of  physic  is  very 
much  modified  from  what  it  was  ;  that  it  is  a  fact  of  universal 
comment.  Now,  why  is  this  so  ?  Why  does  the  profession 
not  abstract  blood,  as  it  formerly  did,  for  almost  every  com- 
plaint ?  Why  are  mercurials  not  given  to  the  same  extent  that 
they  formerly  were  ?  Is  not  the  answer  obvious  ?  It  depends 
on  our  advanced  knowledge  of  pathology,  and  the  consequent 
greater  certainty  in  diagnosis. 

In  this,  as  in  other  medical  matters,  I  desire  to  treat  every 
physician,  as  well  as  his  theory,  with  due  respect ;  but  I  am 
not  called  on  to  hold  my  peace  when  I  honestly  believe  there 
are  errors  to  be  exposed. 

I  shall  now  fairly  and  without  prejudice  enter  on  an  exami- 
nation of  the  essential  nature  of  inflammation,  and  I  hope  that 
I  may  be  able  to  illustrate  the  subject  so  as  fairly  to  bring  it 
to  the  perfect  understanding  of  all  intelligent  physicians. 


INFLAMMATION. 

A  correct  knowledge  of  the  phenomena,  causes,  laws,  ob- 
jects and  results  of  inflammation  lies  at  the  very  basis  of  a 
rational  practice,  either  in  medicine  or  surgery.  Yet  of  this 
important  chain  of  phenomena,  which  is  termed  inflammation, 
80  very  little  is  known  that  one  would  think  the  sentiments  of 
Travens  and  Paget,  of  which  the  above  is  only  a  reflection, 
had  never  been  heralded  to  the  profession.  The  profession  has 
relied  upon  John  Hunter's  explanation,  without  even  asking 
itself  if  that  explanation  was  consistent  with  the  more  exact 
science  of  pathological  anatomy.  The  phenomena  of  inflam- 
mation have  been  misinterpreted  ;  the  productive  causes  have 
been  overlooked ;  the  laws  by  which  it  is  governed  have  been 
unsought ;  the  objects  for  its  establishment  have  not  been  un- 
derstood ;  and,  consequently,  the  end  to  be  attained  by  the 
results  has  been  entirely  misconstrued.  Let  us  examine  as 
many  books  as  we  please  on  the  subject  of  inflammation,  and 
if  we  have  set  out  to  earnestly  investigate  the  subject,  we  shall 
be  di'iven  to  the  conclusions  I  have  expressed  in  the  preceding 
paragi'aph.  I  have  read  so  many  theories  on  the  subject  of 
inflammation,  emanating  from  the  most  eminent  men,  who 
were  so  positive  that  they  had  each  advanced  the  true  theory, 
and  that  all  others  were,  therefore,  wi-ong  ;  and  I  have  found 
so  much  of  the  same  confusion  and  indefinite  expression,  and 


PEACTICE   OF   MEDICINE.  47 

80  much  inconsistency,  not  only  in  those  theories,  but  in  regard 
to  the  simple  laws  of  life — physiology — that  it  is  with  very 
great  hesitancy  I  can  bring  myself  to  the  task  of  attempting  a 
rational  theory  of  inflammation.  It  is  true  that  I  have  these 
theories,  facts  and  experiments  before  me.  It  is  true  that  I 
have  witnessed  all  the  phenomena  usually  seen  in  a  case  of  in- 
flammation ;  that  with  my  chemical  tests  I  have  investigated 
the  character  of  the  blood  when  it  was  present ;  that  I  have 
taken  my  microscope  and  examined  the  minute  structure  of 
parts  in  suCh  a  state ;  yet  I  do  not  feel  that  I  should  be  justified 
in  very  readily  advancing  positive  opinions  in  relation  to  in- 
flammation. I  know  that  many  of  the  movements  of  the  ani- 
mal organism  are  so  obscured  that  we  are  liable  to  very  grave 
errors  of  observation,  and,  therefore,  very  apt  to  adopt  hasty 
conclusions. 

It  is  very  possible  that  I  may  satisfy  ray  readers,  but  I  fear 
that  I  shall  hardly  satisfy  myself  as  to  the  explanation  I  shall 
ofier.  Yet  so  important  is  the  subject,  so  necessary  is  it  to 
comprehend  the  main  features  of  inflammation,  that  if  I  passed 
it  lightly  over,  I  should  regard  the  basis  of  this  work  as  most 
incomplete.  Upon  the  old  pathology  of  the  books,  the  eclec- 
tic practice  would  prove  vastly  injurious  in  the  treatment  of 
inflammation ;  but  our  experience  shows  this  not  to  be  the 
case,  and  if,  therefore,  I  may  not  be  enabled  to  give  a  philo- 
sophical explanation  for  our  practice,  I  shall  have  but  little 
difficulty  in  convincing  the  profession  that  the  old  theories  are 
wrong.  Our  treatment  of  inflammation  is  diametrically  oppo- 
site to  that  of  the  old  system,  or  that  which  is  based  on  the  old 
theories  ;  and  as  it  is  successful,  evidently  our  theory  is  right, 
and  will  so  prove  to  be,  even  though  I  may  not  clearly  express 
that  theory.  I  am  perfectly  aware  that  others  in  the  branch  of 
the  profession  to  which  I  belong,  have  written  on  this  subject ; 
that  they  enjoyed  fine  opportunities  for  observation,  and  yet 
when  I  see  how  little  has  been  done  by  our  best  writers,  I  can- 
not but  feel  that  much  remains  to  be  done — that,  in  fact,  there 
is  no  alternative  but  to  go  back  to  the  diseased  human  body, 
studying  its  morbid  anatomy,  and  closely  watching  the  tissues 
in  all  their  changes. 

This  I  may  not  do  to  my  own  satisfaction,  but  at  least  I  will 
give  the  results  of  my  own  experience,  and  the  consequent 
conclusions.  I  make  no  pretensions  to  infallibility,  and  may 
err  in  my  judgment,  just  as  others  do,  but  I  will  at  least  take 
in  great  kindness  an  exposure  of  my  errors,  because  it  is  my 
earnest  desire  to  arrive  at  the  truth,  and  to  communicate  it  for 
the  common  good  of  my  fellow-men.  It  does  seem  to  me  that 
most  writers  on  the  theory  and  practice  of  medicine  have  failed 
to  recognize  the  absolute  necessity  of  basing  their  practice  on 
clearly  recognized  and  demonstrable  pathological  laws.     And 


48  ECLECTIC    TEEATISE    ON   THE 

in  tracing  these,  we  mnst  not  lose  sight  of  physiology,  or  else 
we  shall  commit  the  grossest  blunders.  The  study  of  every 
function,  whatever  its  state,  may  be  essentially  necessary. 

The  eclectic  branch  of  the  profession  has  not  been  as  well 
represented  in  its  literature  as  we  could  have  wished ;  and  this 
is  so  for  various  reasons,  chief  among  which  has  been  the  dif- 
ficulty of  time,  as  most  of  those  capable  of  writing  have  been 
too  much  engaged  in  practice  to  have  an  opportunity  to  do 
themselves  justice.  It  is  not,  therefore,  strange  that  many 
disconnected  essays  on  the  various  departments  of  the  practice 
should  have  appeared,  when  no  systematic  efibrt  has  been  made 
to  exhibit  the  rational  basis  of  the  school.  But  the  weight  and 
importance  of  this  branch  of  the  profession  is  now  such  that 
the  demand  for  such  a  philosophical  exposition  of  eclecticism 
is  imperative,  and  with  the  view  of  satisfying  this  demand,  I 
am  engaged  on  this  work,  of  which  I  trust  the  profession  will 
have  no  occasion  to  complain. 

With  the  aim  of  presenting  the  sum  and  substance  of  what 
is  really  known  in  reference  to  the  essential  nature  of  inflam- 
mation, I  shall  commence  at  the  very  foundation  of  every 
pathological  state — the  physiology  of  the  animal  frame  ;  for 
in  studying  the  departm'es  from  physiological  action,  we  are 
necessarily  led  to  an  appreciation  of  the  pathological  states. 
Before  proceeding  further,  however,  I  may  be  excused  for  di- 
verging a  little,  so  as  to  examine  very  briefly  the  value  of 
names  as  frequently  applied  to  states  in  medical  science.  By 
a  dogged  adherence  to  names,  which  often  have  no  real  appli- 
cation, or  which  convey  a  wrong  idea  of  the  nature  of  an  af- 
fection or  state,  our  profession  has  stood  greatly  in  its  own 
light.  Thus  we  have  inflammation,  from  injiammo^  to  burn, 
a  name  which,  while  significant  enough  as  indicating  the  in- 
creased heat  or  oxidation  of  the  part,  has  been  made  to  prop- 
agate an  impression  that  the  combination  of  phenomena  which 
we  term  inflammation,  depends  upon  the  presence  of  a  single 
morbid  agent  or  phenomenon,  whose  nature  was  best  repre- 
sented by  the  phrase,  /  hum.  Names  are  frequently  so  very 
arbitrary  as  to  have  no  connection  whatever  ;  and  this  is  so  in 
medicine,  much  too  often  for  the  good  of  society.  There  is 
scarcely  a  ti*eatise  on  medicine  in  which  a  large  amount  of 
space  is  not  occupied  in  solving  the  value  of  names.  For  my 
own  part,  I  have  determined  to  use  as  plain  and  direct  language 
as  I  can,  and  when  I  have  to  use  imperfect  and  inappropriate 
designations,  I  note  and  explain  them. 

I  know  it  to  be  a  thankless  task  to  undertake  the  innovation 
of  new  words,  even  though  the  circumstances  may  require  it.  It 
is  a  matter  of  great  difficulty  to  change  long  established  usage, 
no  odds  what  its  nature  may  be.  It  is  almost  as  difiicult  to 
change  the  ancient  faith  of  a  people  in  religious  matters,  as  to 


PEACTICE   OF   MEDICINE.  49 

introduce  a  new  technical  language  where  one  had  been  previ- 
ously received,  as  we  may  observe  in  the  case  of  the  brain  and 
heart.  The  ancients  referred  all  the  passions  and  sentiments 
to  the  heart,  but  the  moderns  have  shown  the  brain  to  be  the 
instrument  of  intellection,  yet  we  still  hear  of  the  bad  and  good 
heart,  the  warm  afiections  of  the  heart,  etc. ;  and  yet  the  very 
persons  who  thus  cling  to  the  old  technical  language  will  admit 
that  the  passions  and  sentiments  belong  to  the  brain.  Eoki- 
tansky's  idea  that  the  naming  of  disease  is  well  enough,  if  in 
using  those  names  we  simply  dismiss  the  theories  which  first 
led  to  their  adoption,  is  sufiicient  as  far  as  it  goes ;  but  he 
might  have  added,  this  is,  however,  rarely  the  case.  Our 
common  experience  tells  us  that  not  unfrequently  we  hear  the 
advocate  for  one  of  those  old  and  exploded  theories,  appealing 
to  the  etymology  of  the  characteristic  word  in  proof  of  the  cor- 
rectness of  his  position.  The  various  medical  associations 
could  not  do  a  better  deed  than  to  correct  the  errors  of  names. 
As  a  general  thing,  the  names  should  be  anglicised  as  far  as 
possible,  and,  when  this  proves  to  be  difiicult,  then  the  most 
expressive  French,  German,  or  Latin  words  should  be  used. 

It  is  almost  impossible  to  define  inflammation  so  as  to  make 
such  a  definition  satisfactory.  Hence,  if  I  attempt  such  a  defi- 
nition, it  shall  be  after  I  have  clearly  set  forth  the  causes  and 
processes  incident  thereto.  I  am  very  unwilling  to  assume  a 
position,  and  then  bend  the  facts  of  science  to  its  accommoda- 
tion, for  I  have  seen  so  much  of  the  disastrous  results  of  this 
course,  that  I  would  not  willingly  lay  myself  liable  to  the 
criticisms  of  the  profession,  at  least  when  I  myself  should  feel 
the  justness  of  those  criticisms.  In  studying  the  phenomena 
of  infiammation,  we  must  proceed  with  extreme  caution,  and 
without  reference  to  the  theories  in  vogue  at  present,  or  we 
shall  assuredly  not  give  to  each  phenomenon  its  true  value.  We 
are  to  go  back  to  the  body,  and  by  the  aids  furnished  by  the  re- 
searches of  morbid  anatomists,  endeavor  to  learn  not  only  what 
are  the  actual  phenomena  of  inflammation,  but  the  causes  of 
those  phenomena.  When  we  begin  our  work  in  this  way  it  is 
highly  probable  that  we  shall  obtain  the  solution  of  the  vari- 
ous problems  of  inflammation  on  a  correct  basis.  But  even 
here  we  must  exercise  the  greatest  care,  for  evidently  the  in- 
flammation will  be  modified  as  it  occurs  in  difi'erent  tissues, 
and  will  be  more  or  less  marked  as  the  causes  have  been  more 
or  less  severe.  Supposing  that  we  have  commenced  our  ob- 
servation immediately  on  the  establishment  of  the  cause,  and 
the  exciting  cause  and  tissue  to  be  of  average  conditions,  we 
shall  observe  the  following  well  marked  phenomena : 

1.  A    simultaneous    contraction  of  the    capillaries,   and  a 
quickening  of  the  stream  of  blood  passing  through  them. 


50  ECLECTIC    TEEATISE    ON    THE 

But  unless  the  causes  are  only  of  a  moderate  nature,  we  shall 
not  always  observe  these  phenomena. 

2.  This  contraction  of  the  capillaries  is,  sooner  or  later,  and 
possibly  as  a  reaction  of  the  contraction,  followed  by  a  dilata- 
tion of  the  capillaries.  When  the  stimulus  has  been  potent  in 
the  fii-st  instance,  we  may  not  observe  the  contractions  at  all ; 
the  first  visible  phenomena  being  dilatation.  This  has  led  to 
some  errors  in  regard  to  the  phenomena  of  inflammation  in 
the  human  species,  because  the  stimulus  is  not  generally  so  pow- 
erful as  to  produce  the  dilatation  in  such  proximity  to  the  con- 
traction as  not  to  be  noticed,  while  in  artificial  experiments 
on  animals  we  are  very  apt  to  notice  the  dilatation  first  and 
alone,  and  if  we  do  not  reason  well,  may  be  led  to  suppose  this 
is  always  the  case,  irrespective  of  the  productive  causes.  This 
dilatation  of  the  capillaries  is  always  seen,  both  in  the  living 
and  dead  subject ;  nor  shall  we  fail  to  notice  the  simultaneous 
loading  of  the  capillaries  with  an  increased  volume  of  blood. 
It  is  this  injection  or  engorgement  of  the  capillaries  with  an 
increased  amount  of  blood,  that  produces  the  redness  of  in- 
flamed surfaces.  This  enlarged  column  moves  slower  and 
slower  as  the  vessel  becomes  more  and  more  engorged,  until,  as 
Rokitansky  well  remarks,  "  it  merges  in  an  oscillating  move- 
ment of  the  blood  in  the  capillaries."  The  column  moves  on- 
ward and  then  backward,  as  a  tidal  stream,  in  which  the  on- 
ward movement  slightly  predominates. 

3.  The  blood  cells  now  begin  to  agglutinate  and  to  hang 
together,  as  if  by  some  peculiar  attraction.  The  plasma  itself 
does  not  seem  to  have  undergone  much  change,  though  evi- 
dently it  has  been  considerably  modified.  The  cells  have  and 
are  giving  up  all  their  oxygen  ;  an  undue  amount  of  carbonic 
acid  is  being  disengaged,  and  the  cells  themselves  are  being 
speedily  oxydized. 

4.  Stasis,  or  retardation  of  the  blood  in  the  capillaries,  is 
next  noticed.  Cell  on  cell  is  being  crowded  into  the  place 
occupied  by  the  plasma ;  the  cells  become  more  flattened,  and 
of  a  deeper  tinge,  owing,  perhaps,  to  their  greater  number 
and  closer  adherence  ;  they  stick  closely  to  each  other,  and  to 
the  walls  of  the  blood-vessels,  forming  almost  a  common  mass, 
with  an  occasional  interspace  filled  with  nucleated  or  colorless 
corpuscles,  which  have  enormously  increased  their  proportion. 
There  is  also  noticed  now,  two  remarkable  phenomena,  of 
which  we  must  not  lose  sight.  I  refer  to  the  laceration  of  the 
capillaries  and  the  extravasation  of  the  blood  into  the  free 
spaces  of  the  tissue  so  inflamed.  As  a  result  of  this,  where 
the  textures  are  of  a  delicate  nature,  there  is  often  considerable 
hemorrhage,  constituting  what  has  been  termed  capillary  apo- 
plexy, and  the  exosmosis  or  transudation  of  the  serum  through 
the  thinned  walls  of  the  blood-vessels  into  the  parenchyma, 


PEACTICE    OF  MEDICIKE.  51 

infusing  a  dew  as  it  were,  through  the  parts,  which  collects  in 
reservoirs,  as  in  the  case  of  blisters,  bui'ns,  erysipelas,  etc. 
The  seinim  thus  thrown  out  is  that  which  was  formerly  in  the 
blood,  and  resembles  it,  except  that  it  has  given  up  a  part  of 
its  albumen.  This  collection  of  exosmosed  serum  may  advance 
to  external  exudation,  when  it  appears  as  a  moist  dew  on  the 
surface,  from  which  it  is  rapidly  evaporated. 

5.  Genuine  effusion  now  follows.  By  this  I  mean  the  exu- 
dation of  true  blood  plasma,  holding  in  solution  fibrin,  albu- 
men, and  various  salts.  This  is  poured  into  the  interstices  of 
the  parenchyma,  and  may  retain  its  fluidity  or  be  more  or 
less  solid,  especially  if  there  has  been  much  surface  evapora- 
tion. 

So  much,  then,  for  the  attending  phenomena  of  inflamma- 
tion. This  is  the  climax,  for  with  exudation  the  true  inflam- 
matory process  is  ended,  and  the  next  series  of  phenomena  is 
to  get  back  to  the  normal  point  where  all  these  phenomena 
commenced.  From  the  capillaries,  thus  far,  exosmosis  has 
been  the  order.  This  is  now  changed  to  endosmosis  of  the 
serous  portion  of  the  exuded  matter.  Presently  we  observe 
that  the  capillaries  begin  to  contain  more  fluid ;  that  the  blood 
cells  begin  to  float  more  easily,  and  finally  begin  to  separate. 
They  become  more  spherical,  of  a  lighter  color,  and  finally 
begin  to  move  around  through  the  capillaries  in  the  natural 
way. 

These,  then,  are  the  prominent  phenomena  of  a  simple  case 
of  inflammation,  about  which  more  books  have  been  written 
than  I  even  feel  inclined  to  enumerate.  It  will  be  seen  that 
there  is  a  vast  field  for  speculation  and  theory,  and  it  has  been 
well  occupied,  most  assuredly.  For  my  part,  I  shall  pay  but 
little  attention  to  these  speculative  theories,  and  shall  try  to 
confine  myself  as  closely  as  possible  to  what  seems  to  me  the 
pathological  explanation  of  these  phenomena,  always  relying 
on  the  researches  of  the  morbid  anatomists  for  light  on  this 
most  difiicult  subject. 

1.  The  contraction  of  the  capillaries  and  the  attendant  ac- 
celeration of  the  blood  stream  is  a  vital  phenomenon,  and  it  is 
to  be  remarked  that  this  contraction  is  independent  of  any 
and  all  shrinking  up  of  the  surrounding  tissues,  as  we  observe 
when  the  body  or  part  has  been  subjected  to  a  very  low  tem- 
perature. 

2.  The  dilatation  is  always  constant,  and,  as  before  stated, 
often  succeeds  the  contraction  so  very  rapidly  that  it  is  re- 
garded as  the  original  phenomenon.  This  dilatation  is  not  the 
result  of  relaxation  and  exhaustion  merely ;  it  is  the  result  of 
a  series  of  circumstances :  1st,  The  impacting  of  the  blood 
cells  in  the  capillaries  ;  2d,  The  retardation  of  the  blood  in  its 
com-se ;  3d,  The  elasticity  of  the  capillary  walls,  etc. 


52 


ECLECTIC    TREATISE    ON    THE 


With  these  two  phenomena — the  contraction  and  qnicken- 
inp^,  and  dilatation  and  retardation  of  the  vessels  and  blood — 
most  writers  on  inflammation  have  dealt,  but  manifestly  such 
writers  have  not  gone  far  enough ;  they  have  not  watched  the 
phenomena  in  their  varied  changes. 

To  explain  them,  a  very  noted  writer  set  up  a  theory  by 
which  it  is  contended  that  the  contraction  is  owing  to  an  at- 
traction of  the  diseased  parenchyma  for  the  blood,  producing 
exosmosis.  This  theory  regards  the  retardation  of  the  blood 
in  the  capillaries  as  the  primary  phenomenon,  and  the  dilatation 
as  a  subsequent  and  consequential  affair.  The  error  of  this  is 
so  palpable  that  I  need  not  stop  to  refute  it.  But  how  is  this 
attraction  exerted?  This  theory  ascribes  to  the  nerves  the 
power  of  generating  it ;  it  also  uses  the  same  nerves  to  account 
for  the  increased  flow  of  blood  to  the  diseased  part.  The 
dilatation  of  the  blood-vessels  is  accounted  for  in  the  homoeo- 
pathic theory  by  claiming  that  they  do  so  dilate  in  consequence 
of  a  paralysis  of  the  nervous 'fibrils.  That  the  nerves  have 
much  to  do  with  these  phenomena  we  shall  hereafter  see,  but 
the  toning  up  or  depression  of  the  walls  of  the  blood-vessels 
by  their  supplying  nerves  does  not  explain  all  the  distinctive 
phenomena  of  inflammation. 

3.  The  coherence  of  the  blood  disks  is  owing  to  the  same 
causes  which  produce  dilatation — exosmosis  of  serum  and 
mechanical  contact  in  the  confined  walls  of  the  vessels,  as  also 
the  altered  state  of  the  disks  and  remaining  plasma. 

4.  Stasis  is  dependent  on  several  causes.  Among  them  is 
the  coherence  of  the  blood  cells,  and  their  impaction  in  the 
vessels,  and  the  exosmosis  of  the  blood  plasma.  Again,  it  is 
also  promoted  by  the  thickening  of  the  plasma,  the  increase 
of  fibrin  and  albumen,  and  the  transudation  of  serum  through 
the  walls  of  the  blood-vessels ;  and,  what  is  more  important 
than  all  these,  the  accumulation  of  nuclei  and  cell-formation 
and  blood  corpuscles,  their  adherence,  and  the  presence  of  the 
transparent,  fibrinous  coagula,  collectively  developed.  These 
phenomena  are  of  the  greatest  importance,  for  they  clearly 
illusti'ate  the  stasis  itself,  and  at  the  same  time  reveal  the  for- 
mation or  plastic  processes  in  which  the  blood  is  engaged  at 
this  stage.  It  is  here  that  we  observe  the  difference  between 
simple  exudation,  and  the  inflammatory  process.  It  is  at  this 
point  that  we  observe  the  new  formation  elements  arising  out 
of  the  blood,  as  also  the  changes  which  the  blood  itself  is  un- 
dergoing. The  blood  as  now  seen  is  of  a  dark  tile  color,  with 
floating  particles  of  cruor,  twining  with  the  new  formation 
elements,  and  coagula,  in  which  we  observe  a  curious  admix- 
ture of  the  old  flattened  blood  disks,  the  new  formation  ele- 
ments, etc. 

5.  In  the  dilatation  or  enlargement  of  the  blood-vessels, 


PEACTICE    OF   MEDICINE.  63 

there  is  a  consequent  thinning,  so  we  should  have  to  show 
from  whence  this  additional  matter  of  enlargement  was  de- 
rived. This  thinning  of  the  walls  of  the  vessels  lies  at  the 
basis  of  the  phenomenon  of  exudation.  There  is  also  estab- 
lished and  maintained  during  this  phenomenon  all  the  peculi- 
arities of  endosmosis  and  exosmosis — simple,  natural  laws 
alone  being  employed  in  the  production  of  the  phenomenon. 

A  state  of  congestion  surrounds  the  seat  of  the  inflamma- 
tion, and  where  this  is  present,  there  also  occurs  an  efiusion  of 
serum.  The  congestion  is  less  marked  as  we  leave  the  seat 
of  inflammation,  and  also  the  serum  becomes  poorer  in  the 
new  formation  materials.  It  is  this  that  gives  us  the  phe- 
nomena of  oedema  accompanying  inflammation. 

We  come  now  to  the  more  visible  phenomena  of  pain,  red- 
ness, heat  and  swelling.  These  are  always  of  great  import- 
ance in  diagnosis,  because  they  constitute  the  visible  signs 
which  are  to  direct  the  physician . 

The  jpain  incidental  to  inflammation  is  determined  by  a 
variety  of  circumstances,  most  of  which  I  shall  briefly  notice, 
and,  as  I  hope,  in  a  way  to  render  the  subject  intelligible. 

1.  It  is  caused  either  by  the  action  of  the  exciting  cause  of 
the  inflammation  on  the  peripheral  nerves,  or  else  by  a  reflec- 
tion of  these  causes  from  the  central  organs.  But  in  the  lan- 
guage of  Rokitansky,  "  in  no  instance  is  it  determined  by  the 
inflammation  itself;  "  and  yet  it  is  almost  invariably  referred 
to  the  inflammation.  This  is  one  of  the  many  errors  which 
are  to  be  erased  from  the  minds  of  physicians  before  we  can 
expect  that  absolute  correctness  of  practice  based  on  sound 
pathological  principles,  for  which  eclectic  physicians  have 
long  been  contending. 

2.  Inflammation  is  determined  by  the  pressure  incidental  to 
the  distension,  dilatation  and  engorgement  of  the  blood-vessels, 
and  the  distension  of  the  intercellular  spaces  of  the  paren- 
chyma, in  consequence  of  the  attendant  efiusion — all  of  which 
physically  or  mechanically  affect  the  adjacent  nerves.  This  is 
true  inflammatory  pain,  and  is  referable  to  the  abnormal  con- 
dition of  the  parts  involved. 

3.  In  every  inflamed  part,  as  we  have  seen,  there  has  been 
an  increased  oxydation,  and  therefore  an  increased  evolution 
of  carbonic  acid.  Now  there  can  be  no  such  oxydation  and 
evolution  of  carbonic  acid,  except  there  be  also  a  correspond- 
ing elevation  of  temperature.  In  the  presence  of  such  an 
increased  temperature,  the  nerves  are  more  sensitive,  and 
therefore  a  part  of  this  pain,  or  a  certain  degree  of  it,  is  deter- 
mined by  an  increase  of  temperature  of  the  inflamed  part. 

The  redness  is  determined  by  the  undue  injection  of  the 
capillaries  with  blood  cells  or  disks.  It  has  been  already 
shown  that  one  of  the  principal  phenomena  of  inflammation 


64  ECLECTIC   TEEATISE   ON  THE 

was  the  impacting  of  an  excessive  number  of  red  blood  disks 
in  tlie  vessels,  and  it  is  the  increased  number  of  these  which 
determine  the  redness  of  inflammation.  It  was  formerly 
thought  that  in  every  well  marked  case  of  inflammation,  to 
accommodate  the  increased  flow  of  blood  to  a  part  so  inflamed, 
a  large  number  of  new  but  temporary  vessels  were  formed ; 
and  this  increase  of  vessels  was  supposed  to  account  for  the 
increased  redness.  As  it  is  now  known  that  no  such  new 
formation  of  vessels  does  occur,  therelbre  this  was  an  error 
which  in  our  day  and  time  must  be  discarded.  It  may  with 
some  show  of  justness  be  claimed  that  a  part  of  the  increased 
redness  is  owing  to  the  exosmosis  of  blood  during  the  stages 
of  congestion  and  stasis.  In  some  kinds  of  inflammation  the 
blood  pigment  is  dissolved,  and  exosmosed  into  the  tissues. 
This  would  necessarily  produce  a  degree  of  redness  which  has 
been  termed  the  redness  of  imbibition.  The  redness  will  be 
somewhat  altered  in  form  as  the  capillaries  are  distributed  in 
different  ways,  but  this  circumstance  is  by  no  means  important, 
since  in  the  most  delicate  tissues  we  observe  a  uniform  red 
tint,  so  complete  is  the  injection. 

The  intensity  of  the  redness  is  also  dependent  on  the  char- 
acter of  the  inflamed  tissue — that  is,  whether  it  is  more  or  less 
vascular — and  the  intensity  of  the  congestion.  Again,  the 
intensity  of  the  redness  of  inflammation  depends  largely  on 
the  constitution  of  the  blood  itself.  This  we  see  illustrated  in 
syphilitic  and  in  typhus  inflammation,  the  color  being  coppery 
in  the  one  and  violet  in  the  other.  I  have  already  shown  the 
cause  of  the  increased  temperature  of  an  inflamed  part,  but  I 
may  in  addition  remark  that  the  formative  processes  which 
are  going  on  are  themselves  the  result  of  chemical  changes, 
and  in  the  production  of  these  changes  there  is  always  an  in- 
crease of  temperature ;  for  many  of  them  cannot  be  accom- 
plished except  in  the  presence  of  an  increased  temperature. 

The  swelling  is  easily  explainable,  since  it  cannot  but  be 
apparent  that  it  depends  on  the  dilatation  and  engorgement  of 
the  capillaries  ;  upon  the  exudation  of  blood  serum  and  plasma 
in  the  parenchyma,  and  upon  extravasation.  Upon  this  ex- 
udation and  extravasation  depends  that  peculiar  softness  and 
yet  even  solidity  of  inflamed  parts. 

So  much,  then,  for  a  general  description  of  the  phenomena 
of  inflammation.  Upon  a  correct  understanding  of  these,  the 
whole  practice  of  medicine  depends  for  its  rationality. 

Were  I  to  close  this  subject  at  this  point,  I  should  have 
greatly  failed  to  do  full  justice  to  the  subject  of  inflammation. 
Being  aware  of  this,  I  shall  proceed  in  that  inductive  course 
which  I  deem  best  to  lead  the  mind  on,  step  by  step,  until  all 
the  mysteries  of  this  pathological  state  are  clearly  explained. 

It  will  be  understood  that  I  must  now  treat  of  the  varieties 


PEACTICE    OF   MEDICIJTE.  55 

of  inflammation,  the  products  of  inflammation,  and  finally  the 
issues  of  inflammation.  This  labor  I  deem  absolutely  essen- 
tial to  explain  much  that  has  been  said,  and  certainly  much 
that  will  occur  to  the  physician  in  practice.  Of  these  various 
subjects  I  may  be  compelled  to  make  divisions  and  subdi- 
visions, but  I  trust  that  in  the  general  summing  up  every  lact 
will  be  fully  explained  and  understood.  Again,  when  treating 
of  special  disease,  I  shall  be  compelled  to  retrace  much  of  the 
field  of  labor  in  which  I  am  now  engaged,  and  specifically 
consider  the  phenomena  of  each  and  every  case.  It  is  at 
those  places  that  my  readers  should  expect  of  me  a  full  expo- 
sition of  every  minutia.  Did  I  not  know  the  difiiculties  which 
I  have  undertaken  to  remove,  I  should  perhaps  be  willing  to 
enter  into  an  unsystematic  examination  of  this  subject  in  all 
its  details  ;  but  I  believe  such  a  course  would  not  only  confuse 
the  minds  of  m}"^  readers,  but  it  would  lay  me  open  to  the 
promulgation  of  many  an  eiTor,  which  by  system  and  a  close 
study  of  every  part,  I  may  be  able  to  detect  and  avoid. 

The  readers  of  this  work  will  perceive  that  I  have  under- 
taken the  exposition  of  the  errors  of  the  great  mass  of  the 
profession,  and  while  that  would,  in  my  judgment,  be  an  easy 
task,  I  do  not  think  the  work  would  be  a  commendable  one, 
unless  I  can  establish  a  surer  and  more  scientific  basis  for  the 
practice  of  medicine.  That  such  a  change  is  demanded  is,  I 
think,  quite  apparent  when  we  consider  the  want  of  success  in 
general  practice.  That  there  is  a  prospect  for  such  a  change, 
is  apparent  trom  the  rapid  advances  made  by  the  sciences  of 
physiology  and  pathology.  As  we  understand  these  subjects 
better,  we  necessarily  modify  our  practice,  as  we  then  more 
clearly  see  and  comprehend  the  phenomena  of  physiological 
life ;  and  consequently  we  are  more  easily  enabled  to  under- 
stand the  causes  which  are  operative  in  the  production  of  mor- 
bid states  or  pathological  phenomena. 

A  discovery  in  physiology  is  the  signal  for  a  revolution  in 
medicine,  and  the  same  may  be  said  of  pathology.  By  culti- 
vating those  two  branches  of  our  science,  by  collecting  the 
observations  of  all,  and  accurately  weighing  them,  we  shall 
eventually  obtain  positive  theories  on  which  to  base  a  practice 
of  medicine.  It  will  then  remain  for  us  to  correct  our  materia 
medica,  and  then  take  our  stand  boldly  as  the  true  conserva- 
tives of  the  public  health. 

It  may  be  said,  we  shall  never  live  to  see  such  a  triumph  of 
medical  science.  Well,  we  may  not.  We  did  not  witness  the 
laying  of  the  corner-stone  of  the  medical  fabric  by  Hippo- 
crates, and  we  have  no  right  to  refuse  to  labor  for  its  advance- 
ment because,  perhaps,  we  may  not  witness  the  putting  on  the 
cap-stone  of  the  monument  of  medical  science.  It  is  the  duty 
of  each  man  who  enters  this  profession,  to  cultivate  and  adorn 


56         ECLECTIC   TREATISE   ON   THE    PKACTICE    OF   MEDICINE. 

the  science  in  his  own  day  and  generation,  and  then  bequeath 
his  work  to  those  who  are  to  follow  him.  For  my  own  part, 
I  am  satisfied  to  do  a  little  good ;  to  know  at  last  that  I  have 
done  only  a  little  in  polishing  up  and  placing  one  stone  in  the 
walls  of  this  vast  medical  tower,  which  has  ah*eady  been  in 
process  of  erection  four  or  five  thousand  years. 


CHAPTER   IV. 


CLASSIFICATION   OF  THE   VARIOUS   FOKMS   OF  DISEASE. 

Although  the  forms  or  manifestations  of  disease  are  too  nu- 
merous to  admit  of  computation,  yet  all  may  be  arranged  under 
two  heads  or  classes,  the  febrile  and  non-febrile. 

There  is  no  form  of  disease  that  will  not  readily  fall  into 
one  class  or  the  other,  and  between  those  of  the  two  classes 
respectively,  there  is  no  repugnance  of  character.  It  is  true, 
that  sometimes  a  form  which  is  essentially,  in  its  general  char- 
acter, non-febrile,  may  become  febrile,  but  this  is  a  mere  cir- 
cumstance, and  as  an  objection,  its  magnitude  is  not  greater 
than  will  occur  in  any  other  division  that  may  be  attempted ; 
at  all  events,  it  suits  the  circumstances  of  our  present  purpose 
better  than  any  other  that  has  been  suggested  to  us. 

As  it  is  almost  impossible  for  any  physician,  in  the  begin- 
ning of  any  form  of  disease,  to  entertain  a  doubt  as  to  which 
class  it  belongs,  so  this  division  keeps  constantly  before  his 
mind  the  leading  idea  of  his  duty.  The  limits,  ftirthermore, 
that  bound  the  two  classes,  are,  usually  so  clearly  defined, 
that  the  pulse  alone  will  generally  furnish  a  sufficient  diag- 
nosis. 

"We  shall  begin  with  the  febrile  class,  or  that  which  is  dis- 
tinguished by  a  special  manifestation  of  the  vital  force — such 
as  will  frequently,  without  the  aid  of  medicine,  restore  the 
patient  to  health.  There  is  yet  another  reason  why  we  should 
begin  with  the  febrile  class — it  is  more  simple,  because  it  is 
more  easy  to  reduce  force  than  increase  it. 

PYREXIA   OR  FEBRILE   FORMS    OF   DISEASE   IN   GENERAL. 

The  opinions  upon  the  nature  and  character  of  fever  are 
about  as  various  and  as  numerous  as  have  been  their  many 
4 


58  FEBEILE   FORMS    OF   DISEASE,    ETC. 

writers,  and  if  we  commence  their  investigation  with  Hippo- 
crates, who  lived  361  years  before  the  Christian  era,  and  who 
was  probably  the  first  systematic  writer  on  the  subject,  we 
shall  find  them,  as  we  travel  down  to  the  present  time,  to  de- 
part more  and  more  from  our  conceptions  of  the  truth. 

He  regarded  the  human  system  as  being  under  the  direc- 
tion of  a  conservative,  and  in  some  sense,  intelligent  princi- 
ple, which  he  denominated  nature.  Under  such  a  conviction 
he  must  have  believed  that  pathological  manifestations  were 
governed  by  laws  as  fixed  and  as  determinate  as  those  of  gravi- 
tation— that  all  pathological  action  is  just  as  legitimate  and 
as  normal,  under  the  circumstances,  as  any  purely  physiologi- 
cal one.  This  inference  from  the  preceding  premise,  is  com- 
pletely sustained  by  his  opinion  of  disease,  as  set  forth  by  the 
Edinburgh  Practice,  Vol.  I,  page  6  ;  viz :  "  He  imagined  dis- 
ease to  be  only  a  disturbance  of  the  animal  economy,  with 
which  nature  was  perpetually  at  variance,  and  using  her  ut- 
most endeavors  to  expel  the  offending  cause." 

In  this  simple,  consistent  and  beautiful  faith,  he  appears  to 
have  been  well  grounded ;  for  Dr.  Thatcher,  page  4,  says,  that 
"  he  studied  and  copied  nature  with  the  greatest  care  and  as- 
siduity, as  the  only  sure  basis  of  medical  science  ;  and  so  ex- 
tensive was  his  knowledge,  and  so  accurate  were  his  observa- 
tions, that  he  has  been  constantly  held  in  veneration  through 
succeeding  generations."  From  existing  indications,  it  would 
seem,  however,  that  "  succeeding  generations  "  venerated  him, 
not  because  of  his  talents  or  the  accuracy  of  his  observations 
and  discriminations,  but  as  they  generally  do  any  old  anti- 
quated ruin — a  proper  veneration  would  have  dictated  a  closer 
conformity  to  the  immutable  and  salutary  laws  which  he  was 
the  first  to  discover  and  proclaim. 

The  animal  system,  as  a  machine  or  organization,  does  not 
act  intelligently,  but  in  accordance  with  the  laws  of  that  pre- 
existing intelligence  which  designed  it.  Between  this  opin- 
ion and  that  of  Hippocrates,  there  is  not,  practically,  a  shade 
of  difierence,  and  it  is  to  be  presumed  that  no  one  can  be  found 
who  is  so  much  of  an  accidentalist,  as  to  deny  that  the  human 
organization,  either  in  the  abstract,  or  in  its  relations  with  the 
external  world,  does  indicate  wisdom  or  intelligence  in  its  de- 
sign. If  this  conclusion  be  admitted  as  correct,  then  it  fol- 
lows that  Hippocrates  was  in  the  possession  of  a  great  dis- 
covery, when  he  remarked  that  "  Nature  cures  disease  " — that 
is,  disease  is  removed  from  the  system  by  the  agency  of  those 
laws  of  the  organization  which  exist  and  act  in  conformity 
with  a  wise  or  an  intelligent  design.  It  follows  again,  with 
equal  conclusiveness,  that  man  has  no  power  to  cure  disease — 
he  can  only  aid  "  nature^''''  by  acting  in  conformity  with  her 
laws,  and  when  he  acts  otherwise,  he  is  sure  to  defeat  her  in- 


FEBRILE  FOEMS  OF  DISEASE,  ETC.  59 

tentions.     This  conviction  should  be  ever  present  in  the  mind 
of  every  physician,  when  at  the  bedside  of  the  sick. 

We  have  examined  very  many  of  our  standard  and  most 
distinguished  authors  on  the  pathology  of  fever,  but  our  taste, 
judgment,  prejudice,  partiality,  or  whatever  else  it  may  be,  is 
too  fastidious  to  adopt  or  indorse  any  opinion  we  have  found, 
except  that  of  John  Hunter  in  the  abstract,  and  that  of  Tissot, 
in  connection  with  its  treatment.  The  former  says,  that 
"  fever,  in  all  cases  or  of  all  kinds,  is  a  disturbed  action,  like 
inflammation  itself."  And  "  inflammation,"  he  says,  "  is  not 
to  be  considered  a  disease,  but  as  a  salutary  operation  either 
to  some  violence  or  some  disease."  He  again  remarks,  that 
"  pure  inflammation  is  rather  an  effort  of  nature  than  a  dis- 
ease." Then,  according  to  Hunter,  we  may  say  that  "  pure  " 
fever  "  is  rather  an  effort  than  a  disease  ;  "  and,  consequently, 
as  fever  is  but  action,  all  fever  must  be  pure. 

The  latter  author,  Tissot,  says,  that  "  a  fever,  therefore,  that 
has  a  quicker  pulse  than  natural,  and  an  increased  degree  of 
heat,  is  always  salutary  with  respect  to  the  morbific  cause ;  for 
the  effect  of  the  morbific  cause  is  excellently  fitted  to  remove 
the  cause  itself.*  Hence  a  fever  is  justly  defined  by  the  cele- 
brated Sydenham,  to  be  a  "  vigorous  effort  of  nature  to  throw 
off  the  morbific  matter,  which  is  extremely  inimicable  to  the 
human  body,  and  thus  recover  the  patient." 

"  A  fever,  therefore,  which  is  not  too  violent,  but  suited  to 
the  morbific  causes,  ought  not  to  be  extinguished,  if  it  could 
be  done,  but  rather  kept  up  to  promote  their  expulsion." 

It  would  seem  that  there  is  no  war  between  the  Eclectics  and 
Old  School  Allopathists  of  former  days — the  former  are  ac- 
tively engaged  in  repairing,  enlarging  and  elevating  the 
original  edifice ;  while  the  modern  Allopathists  are  not  only 
hostile  to  those  who  abide  in  the  faith,  but  have  disowned 
their  parentage,  as  will  presently  appear. 

Thatcher,  Gregory,  Clutterbuck,  Eush,  Watson,  Eberle, 
Wood,  and  Cheyne,  regard  fever  as  a  disease.  Thatcher  calls 
it  "  the  disease^''  and  the  others  though  not  so  brief,  agree  with 
him.  All  of  them  have  failed  to  find  a  definition  of  fever ; 
and  why  ?  Simply  because  they  have  regarded  it,  as  they  have 
inflammation,  to  be  a  disease,  and  therefore  like  the  latter,  in 
the  language  of  Dr.  John  Thompson,  is,  in  every  case,  either 
an  "  effect.^  a  concomitant^  a  cause,  a  sym/ptom,  or  a  conse- 
quence ^  We  should  indeed  think  it  difficult  to  define  such  a 
proteus. 

Under  an  abiding  conviction  that  no  one  can  be  a  good  or 
a  safe  practitioner  who  is  directed  by  false  principles,  it  be- 


♦Thi»  k  to  be  understood  aocording  to  the  definition  of  Sydenham. 


60  FEBEILE   F0BM8   OF   DISEASE,   ETC. 

comes  our  duty  to  dwell  on  this  subject  to  such  an  extent  as 
we  may  deem  necessary  to  an  exposure  of  the  prevailing  errors, 
and  the  defense  of  those  which  our  convictions  of  truth  com- 
pel us  to  adopt. 

As  it  has  not  been  our  good  fortune  to  find  such  a  definition 
or  conception  of  fever  as  we  can  adopt,  we  are  called  upon  to 
add  one  more  to  the  long  catalogue  with  which  our  medical 
libraries  are  now  burdened.  We  would,  therefore,  define  fever 
to  be  that  amount  of  vital  action,  cceteris  paribus,  which  any 
given,  but  general,  obstruction  to  the  vital  functions  can  pro- 
duce. It  follows,  consequently,  that  that  amount  of  obstruc- 
tion which  would  produce  but  a  slight  fever  in  one  of  strong 
vital  force,  might  produce  death  in  another  of  extremely  feeble 
vital  force.  Consequently  there  can  be  no  grade  of  fever 
which  cannot  be  thus  readily  understood,  so  far  as  regards  its 
modes  of  manifestation. 

As  to  the  location  of  fever  and  its  proximate  cause,  or  as 
we  would  say,  as .  to  the  nature  of  the  disease  that  produces 
fever,  there  are  many  and  widely  difierent  opinions. 

Dr.  Cheyue,  Cyc.  Prac.  Med.,  in  opposition  to  some  of  the 
opinions  we  have  quoted  says,  that  "we  find  the  early  medi- 
cal writers  entertaining  the  idea  that  the  system  waged  war 
against  something  noxious  within  itself,  and  that  in  the  at- 
tempt to  expel  the  ofiending  agent,  a  violent  commotion  was 
excited."  By  this  plausible  theory,  the  duties  of  the  physi- 
cian were  restiicted  to  assisting  nature  in  her  efibrts  to  get  rid 
of  what  was  deemed  injurious  to  the  welfare  of  the  body ;  in 
fact,  fever  was  imagined  to  be  a  natural  and  salutary  process, 
indispensably  necessary  to  throw  ofi"  whatever  was  noxious, 
whether  generated  within  the  body  or  introduced  by  external 
causes." 

This  extract  shows  very  clearly  that  the  author  considers 
fever  to  be  a  disease,  and  that  the  physician  has  something 
more  to  do  than  to  assist  nature.  This  is  particularly  that 
feature  of  the  Old  School  practice  which  we  lament — they 
take  it  upon  themselves  to  remove  disease,  and  so  far  from 
helping  nature,  they  throw  about  one-half  of  her  out-door  in 
the  form  of  blood,  and  the  remaining  half  they  poison  to 
death ;  but  we,  more  humble  in  our  pretensions,  will  feel  en- 
tirely satisfied  with  our  efibrts,  when  we  shall  become  quali- 
fied to  render  the  necessary  aid.  Beyond  this  humble  posi- 
tion we  have  no  ambition. 

We  are  very  much  mistaken,  however,  if  the  author  has  not 
shown  himself  to  be  exceedingly  inconsistent.  In  the  same 
paper  he  remarks:  "It  is  more  than  probable  that  in  what  is 
usually  called  idiopathic  fever,  there  is  alteration  either  of  the 
solids  or  fluids,  although  its  precise  locality  cannot  in  every 
case  be  detected ;  but  without  disease  in  either  the  one  system 


FEBRILE   FOEMS   OF  DISEASE,  ETC.  61 

or  the  other,  we  maintain  that  fever  cannot  exist."  This  is 
precisely  our  position — when  there  is  no  disease  in  the  system 
there  can  be  no  demand  for  fever.  In  the  previous  extract, 
the  inference  is  clear  that  fever  is  disease,  and  that  all  those 
are  in  great  error  who  regard  it  as  an  effort  of  the  vital  force 
to  cast  out  disease,  and  now  he  says,  that  unless  there  is  dis- 
ease fever  "  cannot  exist."  Fever,  then,  is  an  effect,  and  not 
a  disease,  nor  is  it  the  cause  of  the  disease.  Then  it  follows, 
that  fever  is  a  friend  of  the  system — an  effort  of  the  vital 
force,  or  rather  an  accumulation  of  it  for  the  purpose  of  re- 
moving disease,  or  else  it  is  an  enemy  of  the  system,  and  if  so, 
then  it  is  disease,  and  as  such,  it  is  superadded  to  the  disease 
that  caused  it.  Verily,  if  this  is  the  case,  we  need  not  to 
marvel  at  the  difficulty  of  comprehending  it.  No  matter 
where  we  turn,  we  find  nothing  but  confusion  as  to  what  fever 
is,  and  when  we  inquire  as  to  its  proximate  origin,  we  obtain 
nothing  more  satisfactory. 

Many  have,  some  yet  do  contend,  that  the  cause  of  fever  is 
to  be  sought  in  the  fluids,  while  others  are  equally  sure  that 
it  is  in  the  solids.  Some  have  referred  it  to  the  nervous  sys- 
tem, and  some  again  have  attributed  it  to  some  mysterious  or 
occult  organic  inflammation.  Fever  has  been  hunted  for  more 
than  two  thousand  years,  and  yet  its  hiding  places  are  as  lit- 
tle known  as  when  the  search  commenced. 

Dr.  Stevens  is  of  opinion  that  a  morbid  condition  of  the 
blood  is  the  first  link  in  the  chain  of  morbid  phenomena 
that  causes  fever — that  the  serial  or  miasmatic  poison  reaches 
the  blood  through  the  respiratory  function.  He  seems  to  have 
founded  this  opinion  upon  such  facts  as  this :  he  states  that  on 
opening  the  heart  in  fatal  cases  of  yellow  fever,  he  found,  in- 
stead of  blood,  a  dissolved  fluid  nearly  as  thin  as  water  and 
black  as  ink.  In  both  sides  of  the  heart  the  fluid  was  equally 
black,  and  throughout  the  vascular  system  all  distinction  be- 
tween venous  and  arterial  blood  was  completely  lost. 

If  this  supposed  serial  poison  has  the  power  to  do  all  this 
mischief  by  acting  directly  on  the  blood,  it  must  be  considered 
as  exceedingly  singular  that  human  genius  can  devise  no  means 
to  detect  its  presence  in  the  atmosphere,  or  in  the  blood,  or  un- 
der any  other  possible  circumstance.  To  the  doctrines  of  fever 
we  know  of  but  one  parallel,  and  that  is  geology — with  regard 
to  both,  many  facts  have  been  accumulated,  but  the  advocates 
of  both  seem  to  have  banished  common  sense  from  the  field  of 
their  investigations,  and  given  themselves  up  to  the  most  ex- 
travagant speculation  concerning  them — summoning  to  their 
aid  the  most  occult,  hidden  and  extraordinary  causes — such  as 
would  elucidate  nothing  if  admitted. 

As  to  the  remote  cause  of  fever,  there  is  a  pretty  general 
unanimity  of  opinion,  it  is  an  serial  poison,  miasm,  malaria. 


62  FEBBILB  FORMS   OF   DISEASE,  ETC. 

an  ignis  fatuus,  a  something,  a  nothing,  and  yet  it  prodnces 
the  most  fatal  types  of  fever.  It  is  not  our  purpose  to  enter 
further  into  the  discussion  of  this  subject,  or  to  do  more  than 
simply  to  record  our  own  convictions  of  it.  We  have  observed 
enough  to  satisfy  us  that  heat  and  moisture,  with  the  plus  and 
minus  electricity  they  occasion,  and  the  variously  modified 
modes  of  life  among  the  people,  are  adequate  to  all  the  febrile 
results  we  have  noticed  in  connection  with  them. 

We  cannot  believe  that  any  one  will  venture  to  contend  that 
fever  ever  did  take  place  under  a  proper  performance  of  the 
depurating  function.  Inflammation  results  from  local  obstruc- 
tions or  lesions.  Now  suppose  such  obstruction  or  lesion  shall 
be  general — universal  in  the  system,  what  else  could  or  should 
be  expected  than  such  a  reaction  as  constitutes  fever?  Every 
part  and  parcel  of  the  solids  is  so  over  excited,  or  under  ex- 
cited, that  no  one  part,  however  small  or  comparatively  unim- 
portant, is  able  to  eliminate  its  metamorphosed  portions — the 
absorbents  are  as  it  were  dead.  The  glandular  structures,  too, 
are  in  a  similar  condition,  and  hence  all  the  impurities  of  the 
venous  blood,  because  of  defective  depuration,  becomes  mixed 
or  blended  with  the  arterial,  and  this  morbidly  excites  every 
part  and  fever  results. 

It  is  well  known  that  a  hot,  dry  season  is  measurably  ex- 
empt from  febrile  epidemics,  but  if  rain  be  added  to  this  heat, 
then  they  appear.*  We  are  told  that  it  is  because  the  two 
combined  promote  vegetable  decomposition.  If  this  explana- 
tion be  adopted,  how  shall  we  account  for  some  epidemics  in 
sandy  deserts,  far  removed  from  any  source  of  malaria  ?  It  is 
well  known  that  children  and  negroes  are  greatly  exempt  from 
the  malarious  fevers  of  the  South.  If  then,  these  fevers  are 
produced  by  a  poison,  how  does  it  happen  that  they  are  ex- 
empted? If  our  position  be  correct,  this  fact  is  easily  ex- 
plained. The  black  surface  of  the  negro  radiates  not  only  a 
large  portion  of  his  animal  heat,  but  also  a  large  portion  of 
that  solar  heat  that  falls  upon  him  ;  and  another  large  portion 
is  removed  by  the  evaporation  of  his  perspirable  matter.  With 
these  advantages  his  skin  maintains  its  integrity,  and  as  no 
morbid  sympathy  is  engendered  between  it  and  the  liver,  the 
kidneys  and  other  glandular  structures,  a  proper  depuration 
of  the  system  does  not  become  suspended ;  and  as  to  children, 
they  are  confined  mostly  to  the  house.  But  they  Have  another 
means  of  protection — it  is  that  thick  coat  of  adeps  which  is 
common  to  their  age,  and  to  some  forms  of  these  epidemics 
such  men  are  equally  invulnerable. 

*  TMs  is  not  the  fact,  with  reference  to  the  yellow  fever  of  New  Or- 
leans ;  a  hot,  dry  season  is  the  most  productive  of  it ;  we  admit  the  state- 
ment, however,  as  regards  intermittents. 


FEBEILE  F0BM8   OF   DISEASE,  ETC.  63 

No  medical  philosopher,  we  should  think,  could  have  la- 
bored for  many  weeks,  contrary  to  his  custom,  in  a  hot  sun, 
with  the  other  epidemic  requisite,  and  not  comprehend  how  it 
was  he  contracted  fever.  He  exhausted  his  skin — many  in- 
ternal organs  sympathized  with  it,  particularly  the  liver  and 
mucous  membrane  of  the  bowels,  and  thus,  without  the  preva- 
lence of  moisture,  he  may  be  seized  with  dysentery — ^but  with 
the  moisture  he  will  have  some  form  of  fever — his  skin  is  too 
feeble  to  contend  with  a  greatly  reduced  electric  condition  of 
the  atmosphere,  constriction  of  it  ensues,  then  comes  a  chill, 
and  then  a  reaction  which  is  denominated  fever.  As  the  ob- 
struction is  universal,  the  result  is  fever,  and  cannot  .be  in- 
flammation, and  therefore  it  appears  about  as  consistent  to  talk 
about  a  general  or  a  universal  congestion  as  about  an  inflam- 
matory fever. 

These  views  of  fever  strike  us  as  being  the  legitimate  re- 
sults of  common  sense  and  common  observation,  and  do,  with 
clearness  and  force,  point  out  the  necessary  indications  of  treat- 
ment. With  a  normal  depuration,  fever  cannot  obtain,  and 
without  it,  it  cannot  be  cured,  but  it  may  be  replaced  by  a 
mecurial  disease,  or  some  other,  or  the  patient  may  be  killed, 
or  sufiered  to  die  for  the  want  of  an  adequate  treatment. 

We  are  aware  that  very  many  apparently  conclusive  facts 
can  be  brought  to  bear  in  favor  of  malarious  poison,  but  let  it 
be  remembered  that  laws  or  rules  have  no  exceptions,  and 
therefore  the  production  of  a  single  epidemic,  of  the  same 
kind,  under  circumstances  that  positively  contra-indicate  the 
existence  of  such  a  poison,  is  enough  to  destroy  the  doctrine — 
one  affirmative  fact  is  worth  any  number  of  negative  ones. 

Our  observation  proves  that  where  a  person  has  a  low  ca- 
loric and  electric  condition,  the  patient  generally  possessed  a 
comparatively  feeble  vital  force,  or  Professor  Hall's  high  dy- 
namis,  and  therefore  could  not  bear  a  greater  reduction  of  these 
stimuli.  In  the  cases  of  continued  or  remittent  (synocha)  fever, 
to  be  confined  to  constitutions  of  high  vital  force,  or  according 
to  Professor  Hall's  Zoonomia,  high  stimulus ;  and  therefore 
could  not  bear  more,  as  the  high  caloric  and  electric  atmos- 
phere. 

With  reference  to  fever  in  general,  we  remark  that  it  does 
not  matter  what  may  be  the  number  or  the  variety  of  the  forms 
under  which  it  may  appear,  it  is  essentially  a  unit — it  has  an 
increased  action  of  all  the  fibrous  tissues  for  the  removal  of 
disease  or  obstruction ;  nevertheless,  for  the  convenience  of 
study,  its  forms  may  be  divided,  and  with  much  propriety, 
into  two  orders  ;  first,  those  which  result  from  general  obstruc- 
tion and  therefore  attended  with  fever ;  and  secondly,  those 
that  result  from  obsti'uction,  and  consequently  attended  with 
inflammation. 


64  FEBRILE  FORMS   OF  DISEASE,  ETC. 

"We  have  too  much  to  learn  about  the  atmosphere,  as  re- 
gards caloric,  electricity  and  humidity,  to  conclude,  when  it  is 
fatal  to  animal  life,  that  there  is  in  it  some  foreign  poison. 
The  conclusion  in  this  instance  has  been  as  much  too  hastily 
drawn  as  that  of  the  geologists  in  referring  mineral  coal  to  a 
vegetable  origin,  upon  the  flimsy  evidence  that  the  coal  shales 
contain  vegetable  impressions.  Such  hasty  generalization 
has,  and  now  is  doing  much  to  retard  the  advancement  of 
science.  Of  this,  we  have  one  flagrant  example :  the  whole 
medical  world  has  admitted  that  some  forms  of  disease  are 
hereditary,  and  this  general  admission  has  closed  the  door  to 
any  useftd  investigation  on  the  subject — and  yet  the  character 
of  the  error  has  but  to  be  named  to  be  clearly  perceived. 

We  have  not  dwelt  upon  this  subject,  to  the  least  extent, 
with  any  expectation  or  even  a  desire  to  convert  any  one  to 
our  convictions  of  the  truth,  but  for  the  purpose  of  awaking 
fresh  observation — for  the  purpose  of  breaking  up  or  disturb- 
ing that  settled  conviction  of  the  truth  of  a  conclusion  which 
may  possibly  be  false. 

CONTINUED    FEVEB   AND    PERIODIC   FEVER. 

Before  proceeding  to  the  consideration  of  these  genera,  it 
may  be  profitable  to  dwell  a  while  on  the  phenomena  that 
usually  constitute  the  course,  type  and  stages  of  fever.  The 
course  of  a  fever  is  determined  by  its  phenomena  being  con- 
tinued, remitting  or  intermitting,  and  that  series  of  phenomena 
which  characterize  this  course  may  be  usefully  divided  into 
the  following  periods  or  stages  :  1,  the  forming ;  2,  the  cold ; 
3,  the  hot;  4,  the  sweating,  and  6,  the  final.  There  are  so 
many  interesting  and  usefal  phenomena  in  the  first,  that  we 
have  preferred  to  embrace  it,  though  conti*ary  to  the  custom 
of  many.  As  the  final  period,  that  of  convalescence  or  dis- 
solution, is  of  equal  interest  with  the  first,  we  have,  in  com- 
pany with  some  authors,  thought  it  best  to  include  it  also. 

It  should  be  remembered,  however,  that  we  are  not  to  ex- 
pect to  find  all  of  these  stages  clearly  defined  in  any  one  of 
the  febrile  forms,  except  the  intermitting;  nevertheless,  pe- 
riodicity characterizes,  more  or  less,  every  form  of  disease ; 
but  this  law  is  not  particularly  conspicuous  in  the  violent  and 
continuous  forms  of  fever,  and  yet  it  but  rarely  happens  that 
the  primary  or  oppressive,  the  febrile  or  exciting,  and  the  de- 
clining stages  of  all  forms  of  fever  are  not  suflBciently  marked 
to  be  clearly  observed. 

1.  Period  of  Formation. — This  is,  in  reality  the  period  in 
which  the  vital  forces  are  preparing  for  the  removal  of  exist- 
ing disease,  or  obstruction  to  the  normal  manifestation  of  the 
physiological  functions,  it  is  that  period  which  intervenes  be- 
tween the  first  morbid  sensations,  and  the  introduction  of  the 


FEBBILB  F0BM8   OF  DISEASE,  ETC.  65 

febrile  phenomena.  Its  duration  varies  exceedingly,  and  this 
depends  more  upon  the  resisting  character  of  the  invaded  con- 
stitution than  upon  other  contingencies.  In  the  highly  vital, 
this  period  is  occasionally  so  short  as  not  to  be  observed — the 
febrile  attack  is  absolutely  one  of  surprise  and  astonishment. 
In  such  constitutions  the  faculty  of  animal  sensibility  is  so 
strong,  and  therefore  vigilant,  that  upon  the  slightest  inva- 
sion, the  other  vital  powers  are  immediately  summoned  to  re- 
sistance. 

In  constitutions  of  a  contrary  character,  this  period  may  be 
greatly  prolonged.  The  obstruction  is  permitted  to  increase 
and  spread,  until  at  length  the  physiological  functions  become 
very  much  arrested — too  much  so  for  a  normal  continuance  of 
life,  and  then  a  struggle  ensues  which  is  indicated  by  a  rigor 
or  a  chill,  which  is  succeeded  by  fever. 

The  first  indication  of  this  podromal  stage  is  an  indisposi- 
tion to  attend  to  business — a  feeling  of  weariness,  an  indefin- 
able anxiety — the  appetite  still  being  good.  Then  succeeds  a 
sense  of  lassitude ;  disturbed  sleep ;  loss  of  appetite ;  yawn- 
ing and  stretching ;  wandering  pains  in  the  limbs  and  back, 
and  unpleasant  sensations  in  the  stomach ;  harsh  and  dry  skin  ; 
irregularity  of  the  bowels,  but  most  generally  constipated ; 
some  headache ;  flatulence ;  nausea ;  the  drying  up  of  old 
sores  ;  giddiness ;  tremors  of  the  extremities ;  slight  creeping 
sensations  of  cold,  and  an  indisposition  to  be  satisfied  with  the 
usual  modes  of  existence.  In  reviewing  these  symptoms,  as  a 
group,  we  are  bound  to  perceive  that  the  nervous  system  has 
become  greatly  impaired,  and  that  its  susceptibility  to  normal 
impressions  has  become  blunted. 

2.  The  period  of  rigor  or  chill. — The  first  indication  of  the 
approach  of  this  stage  is  a  sensation  of  chilliness  which  may 
be  confined  to  the  loins,  or  to  one  or  more  of  the  extremities, 
or  to  the  spine,  while  the  other  portions  of  the  body  feel  to 
be  comfortably  warm.  This  state  of  the  system  gradually 
passes  into  one  of  tremor,  which  first  becomes  manifest  in  the 
inferior  jaw,  and  thence  extending  to  the  entire  muscular  sys- 
tem. In  the  firmer  class  of  constitutions  it  but  rarely  exceeds 
a  chill  and  slight  tremor ;  but  in  less  resisting  constitutions  it 
is  sometimes  very  severe — so  much  so  that  it  has,  according 
to  authorities,  produced  convulsions. 

The  patient  has  not  only  a  sensation  of  cold,  but  his  skin 
does  become  cold,  and  Dr.  Wilson  Philip  says  that  its  tem- 
perature has  been  known  to  fall  as  low  as  70°  Fahrenheit. 
This  condition  of  the  animal  temperature  becomes  indicated 
by  the  paleness  of  the  lips,  nails,  fingers  and  toes — sometimes 
they  become  of  a  purple  or  livid  color.  The  skin  on  most 
parts  of  the  body  becomes  greatly  constricted  and  drawn  into 
little  elevations  or  papules,  like  those  of  the  feathered  tribe 


66  FEBKILE   FOBMS    OF   DISEASE,  ETC. 

when  the  feathers  are  removed.  The  pulse  during  this  stage, 
is  small  and  quick,  and  frequently  irregular ;  the  breathing, 
like  the  pulse,  is  hurried  and  labors  under  a  feeling  of  con- 
striction in  the  praecordia. 

During  this  stage,  the  patient  makes  no  demand  for  food, 
but  his  thirst  is  sometimes  very  considerable ;  the  secretions 
are  not  only  in  a  great  measure  suspended,  but  much  de- 
ranged— the  saliva  is  scanty  and  viscid ;  in  some  instances 
much  gastric  derangement  obtains,  as  frequent  retching  and 
vomiting ;  and  occasionally  this  irritation  is  extended  to  the 
bowels  and  liver,  which  is  attended  with  a  purging  of  bilious 
matter.  These  symptoms,  however,  are  mostly  confined  to 
southern  latitudes,  but  in  all  latitudes  this  stage  is  so  mild 
that  the  patient  himself  does  not  become  conscious  of  it — it  is 
indicated  only  by  some  paleness  of  the  lips  and  a  little  cool- 
ness of  the  hands  and  feet. 

The  length  of  time  occupied  by  this  stage  is  very  variable 
— continuing  from  a  few  minutes  to  four  or  five  hours,  but  one 
hour  and  a  half  may  be'assumed  as  the  average  duration.  It 
may  be  valuable  to  remark,  however,  that  this  period  is  gen- 
erally more  protracted  in  southern  than  temperate  latitudes ; 
but  in  all  latitudes  it  may  be  well  to  add,  that  the  more  this 
stage  is  contracted,  the  more  protracted  and  severe  Avill  the 
hot  one  be.  When  we  reflect  that  the  chill  is  always  in  the 
inverse  ratio  to  the  vital  or  reactive  force,  the  reason  of  this 
is  readily  understood  ;  and  hence  it  is  that  when  the  vital  re- 
sistance or  reaction  cannot  be  effected,  the  patient  dies  in  the 
chill. 

When  the  reaction  has  been  effected  and  completed,  flush- 
ings of  heat  become  blended  with  those  of  the  chill ;  the  pa- 
tient breathes  with  more  ease,  and  gradually  removes,  piece 
after  piece,  the  bed-clothing  ofi"  his  body,  and  finally  from  his 
extremities.     The  hot  stage  has  commenced. 

3.  The  period  of  increased  temperature. — When  the  tem- 
perature begins  to  rise  out  of  the  rigor,  it  is  felt  by  the  patient 
to  be  a  great  relief,  but  when  it  reaches  its  maximum  inten- 
sity, he  finds  himself  as  uncomfortable  as  when  at  the  other 
extreme.  He  first  becomes  sensible  to  the  introduction  of  this 
stage  about  the  face  and  eyes,  and  then  the  thorax,  the  abdo- 
men, and  finally  the  extremities.  When  the  reaction  is  ren- 
dered difficult,  sensations  of  heat  and  cold  alternate,  and  fre- 
quently for  some  time,  but  finally,  in  such  cases,  the  former 
obtains  the  ascendency.  The  patient  finally  begins  to  feel  hot, 
and  the  sensation  is  not  delusive,  for  the  condition  of  his  sur- 
face produces  the  same  sensation  to  the  tact  of  others,  and 
further,  it  becomes  demonstrable  by  elevating  the  mercury  to 
105°,  and  in  a  few  instances  to  107°,  when  the  bulb  is  placed 
under  the  tongue. 


FEBRILE   F0BM8    OF   DISEASE,  ETC.  67 

With  this  increase  of  temperature  there  is  usually  a  very 
considerable  acceleration  of  the  circulation,  but  in  this  par- 
ticular there  is  much  variation.  When  the  vital  force  and  the 
obstruction  are  so  related  as  to  render  the  reaction  easy,  the 
pulse  is  full,  strong,  and  quick,  but  without  a  remarkable  fre- 
quency, not  much  more  than  is  common  to  health.  But  when 
the  condition  is  reversed,  the  pulse,  in  all  respects,  falls  below 
the  normal  standard,  except  as  to  its  frequency,  being  some- 
times increased  to  110,  and  from  this  to  160  beats  in  a  minute ; 
but  while  there  is  good  velocity,  there  is  indicated  a  great 
want  of  arterial  power,  for  it  is  soft  and  easily  compressed. 
If  inflammation  be  located  in  any  special  part,  it  will  be  indi- 
cated by  a  tense,  small,  and  contracted  pulse. 

The  brain,  as  a  matter  of  course,  participates  with  the  other 
parts  of  the  system,  and  hence,  in  this  stage,  the  senses,  ex- 
cept those  of  smelling  and  tasting,  become  more  acute,  the 
brain  is  very  frequently  afflicted  with  pain,  more  particularly 
with  those  who  possess  dense  and  fibrous  constitutions ;  and, 
moreover,  if  the  fever  run  very  high,  delirium  is  a  very  gen- 
eral consequence.  It  is  quite  common  in  this  stage  for  the 
patient  to  complain  much  of  pain  in  the  back,  the  extremities 
and  other  portions  of  the  body ;  he  is  also  troubled  with  a 
morbid  vigilance — an  indefinable  uneasiness  and  restlessness. 

The  digestive  system  is  not  without  equal  manifestations  of 
derangement.  A  loathing  of  food  and  warm  drinks,  with  a 
desire  of  cold  drinks,  are  peculiarly  characteristic  of  this  stage. 
Isausea  and  vomiting,  constipation  or  diarrhea,  but  more  li*e- 
quently  the  former ;  a  disagreeable  taste  in  the  mouth,  a 
furred  tongue  with  clean  tip  and  edges,  are  also  very  common 
symptoms. 

The  secretions  are  generally  very  much  arrested ;  the  urine 
is  scanty  and  high-colored ;  the  skin,  tongue  and  mouth  are 
usually  dry,  and,  in  the  most  favorable  cases,  the  bowels  are 
dry  and  constipated. 

The  duration  of  this  stage  is  as  uncertain  as  that  of  the  pre- 
ceding ;  it  sometimes  ceases  in  a  few  hours,  but  in  many  in- 
stances it  continues  for  days  and  even  weeks.  Finally,  it 
should  be  remembered,  that  all  of  these  symptoms  become 
very  much  modified,  in  difierent  cases,  by  circumstances  inci- 
dental to  the  cause,  the  constitution  or  the  peculiarities  of  the 
occasion. 

4.  The  ^period  of  per^iration. — When  the  previous  stage 
has  become  so  far  reduced  in  temperature  as  to  admit  of  se- 
cretion, perspiration  begins  to  break  forth  upon  the  superior 
portions  of  the  body,  and  gradually  extends  over  the  whole 
surface.  It  is  sometimes,  as  to  quantity,  quite  moderate,  but 
in  many  instances  it  becomes  highly  profuse.  When  this 
period  has  continued  for  some  time,  it  subsides,  leaving  all  the 


DO  FEBKILE   FOBMS    OF   DISEASE,  ETC. 

functions  very  much  in  their  normal  condition,  except  that  they 
are  much  weakened. 

The  preceding  four  periods  succeed  each  other  in  regular 
order ;  nevertheless,  they  present  much  diversity  of  character 
in  the  diiferent  forms  of  the  disease,  as  may  be  noticed  when 
we  come  to  treat  of  them  individually. 

5.  The  period  of  conclusion. — The  disease  for  the  removal 
of  which  the  fever  was  instituted,  was  proximately  occasioned 
by  an  insufficient  depuration,  so  when  this  function  begins  to 
re-establish  itself,  and  this  stage  begins  in  a  favorable  manner, 
the  patient  will  recover,  in  the  event  of  no  unfavorable  inter- 
ruption. On  the  other  hand,  if  the  function  of  depuration  be 
not  re-established,  the  chemical  agencies  acquire  an  ascen- 
dency over  the  vital,  then  this  period  is  occupied  by  the  pro- 
gress of  dissolution.  Hence  it  is,  that  when  the  declination  is 
favorable,  its  beginning  is  indicated  frequently  by  the  spon- 
taneous occurrence  of  a  profuse  perspiration,  urination,  bilious 
or  serous  discharges  from  the  bowels,  which  have  been  denomi- 
nated critical. 

We  cannot  avoid,  in  this  place,  to  notice  a  remark  of  Dr. 
Wood,  who  says,  "  It  has  been  conjectm-ed  that  these  evacu- 
ations were  the  means  by  which  nature  effected  the  cure  of  the 
complaint ;  and  the  idea  at  one  time  extensively  prevailed  that 
through  their  instrumentality  offensive  matter,  which  served 
to  sustain  the  fever,  was  eliminated  from  the  system.  With- 
out attempting  here  to  confute  this  hypothetical  notion,  it  is 
sufficient  to  say  that  the  discharges  are  the  necessary  results 
of  a  certain  grade  of  irritation  in  the  organs,  and  if  they  serve 
to  relieve  the  disorder  in  which  they  originate,  it  is  only  one 
of  the  numerous  instances  in  which  nature  has  contrived  to 
make  noxious  influences  subservient  to  their  own  removal." 

K  the  bills  of  mortality  could  either  speak  or  write,  they 
would  publish  a  most  lamentable  account  of  those  who  prac- 
tice upon  the  doctrine  here  set  forth  by  this  distinguished  pro- 
fessor. It  is  too  glaringly  absurd  to  require  of  us  more  than 
a  very  few  common  sense  interrogatories  and  comments. 

Will  the  doctor  or  any  one  else  affirm  that  the  patient  would 
or  could  have  recovered  without  the  elimination  of  the  morbid 
and  offensive  matter  which  is  now  under  consideration  ?  How 
did  that  "certain  grade  of  irritation  in  the  organs"  happen? 
Was  this  matter  elaborated  by  the  irritation,  or  was  it  the 
cause  of  the  irritation  ?  If  the  "  instances  "  of  such  elimina- 
tions are  "  numerous,"  should  we  attribute  them  to  nature's 
bungling,  or  to  a  law  of  her  settled  policy  ?  If  nature  very 
frequently  bungles  in  this  way,  it  would  be  a  happy  circum- 
stance to  society  if  the  doctors  woald  suffer  her  to  manage  all 
cases  in  her  own  way. 

K  secretion  becomes   arrested  or  deranged  by  miasmatic 


FEBRILE   F0EM8   OF  DISEASE,  ETC.  69 

poison  (?),  heat,  cold,  minus  or  plus  electricity,  or  any  other 
cause,  and  the  matter  which  ought,  normally,  to  have  been 
eliminated,  is  not,  will  it  not  act  upon  the  irritability  of  the 
system  as  foreign  matter  ?  And  if  the  retention  of  such  mat- 
ter did  not  produce  a  "  certain  grade  of  irritation,"  and  even 
fever,  could  the  system  be  in  a  normal  or  physiological  condi- 
tion? Is  there  not,  sometimes,  too  much  carbon,  urea,  or 
lime,  or  phosphorus,  in  both  the  fluids  and  solids  of  the  sys- 
tem ?  Has  the  system  any  other  remedy  for  this,  its  condi- 
tion, than  secretion  and  depuration  by  the  skin,  kidneys,  liver, 
the  mucous  membrane  of  the  bowels,  etc.  ?  And  are  not  those 
eliminations  which  take  place  in  the  crisis  of  fever,  of  this 
character  ?  Do  they  not  absolutely  produce  it,  and  thus  ter- 
minate the  fever  by  removing  its  cause  ? 

In  such  instances  nature  has  effected  the  very  result  which 
should  be  the  object  of  the  physician  trom  the  moment  he 
visits  a  patient ;  indeed,  he  was  called  for  the  purpose  of  help- 
ing her  to  do  in  less  time  that  which  she  may  ultimately  effect 
without  help. 

One  of  the  most  indubitable  evidences  of  the  commence- 
ment of  this  period — of  the  re-establishment  of  secretion — is 
the  moistening  and  cleaning  of  the  tongue.  This  cleaning 
process  commences  at  the  point  and  edges,  and  gradually 
progresses  until  the  whole  is  clean  and  brought  to  a  normal 
appearance.  These  changes  in  the  tongue  indicate,  no  doubt, 
that  nature  is  "  contriving  "  to  do  the  same  for  the  whole  gas- 
tro-intestinal  canal,  in  connection  with  a  general  secretory 
movement — the  execution  of  the  plan  "  which  nature  has  con- 
trived to"  remove  a  "  certain  grade  of  irritation  in  the  or- 
gans," instead  of  being  the  result  of  it. 

With  the  indications  of  returning  health,  above  named,  may 
be  expected  a  pari  passu  movement  of  all  the  secretions,  and 
a  corresponding  return  of  the  senses,  appetites  and  propensi- 
ties to  their  normal  condition. 

Before  dismissing  this  subject,  it  is  proper  that  we  add  a  few 
remarks  upon  what  is  usually  denominated  the  types  of  fever, 
and  as  Dr.  Eberle's  descriptions  are  better  or  more  clear  than 
those  of  most  writers,  we  shall  adopt  his  account  of  them. 

He  says,  "The  space  of  time  occupied  by  one  paroxysm  of 
aJever  and  its  succeeding  intermission,  or  which  intervenes 
between  the  regular  periodical  exacerbations  of  paroxysmal 
fever,  is  called  the  revolution  of  a  fever.  The  revolutions  of 
fevers  are  various  in  point  of  duration  ;  some  fevers  complet- 
ing theirs  in  twenty -four  hours ;  others  in  forty-eight,  while 
others  require  seventy-two,  and  some  even  ninety-six  hours. 
The  form  which  a  fever  assumes,  in  this  respect,  is  called  its 
type;  so  that  a  fever  which  occupies  twenty-four  hours,  from 
the  commencement  of  one  paroxysm  to  another,  is  said  to  be 


iPflh  FEBEILE    FOKMS    OF   DISEASE,  ETC. 

of  the  quotidian  type ;  while  one  which  revolves  every  forty- 
eight  hours,  is  of  the  tertian  type ;  and  when  this  period  is 
extended  to  seventy-two  hours,  the  fever  is  of  the  quartan 
type ;  and  a  period  of  ninety -six  hours  constitutes  the  quintan 
type.  The  quotidian^  the  tertian^  and  the  quartan  types,  con- 
stitute the  three  principal  and  primary  types  of  liever ;  all  of 
which  are,  however,  subject  to  modifications  which  may  read- 
ily mislead  the  careless  observer,  so  as  to  confound  them,  or 
mistake  one  for  the  other,  especially  the  quotidian  and  the 
tertian. 

"It  has  been  observed,  that  in  fevers  of  the  quotidian  type, 
the  paroxysms  generally  come  on  in  the  morning — a  circum- 
stance, which  has  been  almost  invariably  verified  in  my  own 
experience,  and  which  is,  indeed,  so  constant,  that  Cullen  was 
induced  to  notice  it  in  his  definition  of  a  quotidian.  Tertians 
commonly  come  on  toward  noon  ;  but  they  are  much  less  regu- 
lar, in  this  respect  than  fevers  of  the  preceding  type.  Two 
simple  tertians  sometimes  go  on  cotemporaneously  in  the  same 
patient ;  so  that,  instead  of  the  paroxysms  recurring  only 
every  other  day,  they  occm-  daily,  as  in  a  quotidian.  These 
cases  are  called  double  tertians.^  and  are  distinguished  from 
quotidians  by  the  paroxysms  of  the  alternate  days  being  sim- 
ilar in  relation  to  the  precise  time  of  their  occurrence,  grade 
of  violence,  duration,  and  other  circumstances.  Thus  the  par- 
oxysms on  the  odd  days,  will  perhaps  recur  at  nine  o'clock  in 
the  forenoon,  while  those  which  happen  on  the  even  days  will 
come  on  at  two  or  three  o'clock  in  the  afternoon,  so  that,  al- 
though each  day  has  its  paroxysms,  the  fever  cannot  be  prop- 
erly considered  as  a  quotidian,  but  the  cotemporaneous  progress 
of  two  simple  tertians,  the  one  having  commenced  a  day  sooner 
than  the  other.  Fevers,  however,  rarely  assume  the  double 
tertian  type  from  their  commencement.  They  usually  begin 
and  continue  for  some  time  in  the  simple  tertian  type — the  du- 
plication occurring  afterward ;  and  when  the  type  thus  becomes 
doubled,  the  new  or  accessory  paroxysms  are  in  general  con- 
siderably milder  than  those  of  the  original  or  simple  tertian. 
It  is  asserted,  that  a  double  tertian  seldoms  terminates  without 
first  assuming  the  single  tertian  type,  the  accessory  or  weaker 
paroxysm  disappearing  first." 

CONTINUED    FEVER. 

Introduction. — It  will  be  remembered  that  we  divided  the 
various  forms  of  fever  into  two  orders,  and  the  first  of  these 
again  into  two  genera — the  continued  and  the  'periodic^  and 
although  this  arrangement  has  many  practical  advantages,  yet 
it  is  not  strictly  true.  It  appears,  so  far  as  observation  has  ex- 
tended, that  the  functions,  of  every  variety  of  organization, 


FEBBILE   FOBMS   OF   DISEASE,  ETC.  71 

are  subjected  to  a  species  of  periodicity,  and  this  law  is  com- 
mon to  both  health  and  disease.  Consequently  it  is  exceed- 
ingly rare  to  witness  any  variety  of  febrile  action  which  does 
not,  to  some  extent,  indicate  the  presence  of  this  law.  And 
yet  the  decrease  or  abatement  of  febrile  action,  in  this  genus, 
is  so  inconsiderable,  when  compared  with  the  other,  as  to  leave 
no  room  for  a  mistake  in  the  diagnosis. 

The  modifications  of  this  genus  are  so  numerous  and  promi- 
nent as  to  have  led  to  considerable  confusion  among  writers, 
and  the  names  which  the  several  modifications  have  received, 
are  almost  as  numerous  as  have  been  the  writers.  The  two 
extremes  of  this  genus,  as  relates  to  the  energy  of  their  action, 
has  caused  it  to  be  divided  into  two  species  the  sthenic  and 
asthenic^  or  inflammatory  and  typhous.  That  there  is  a  very 
great  difference  between  the  highest  grade  of  the  sthenic  and 
that  of  the  asthenic  no  one  will  question,  but  to  regard  a  fever 
as  inflammatory  that  originates  in  general  obstruction,  is  equiv- 
alent to  contending  for  an  impossibility;  nevertheless,  as  a 
name,  it  is  now  understood,  and  hence  we  shall  not  depart  from 
its  accepted  use.  In  order  to  convey  some  idea  of  the  grades 
of  febrile  manifestations,  they  have  been  divided  into  three  va- 
rieties :  synocha^  synochus^  and  typhous.  The  first  is  intended 
to  embrace  those  febrile  forms  which  have  been  denominated 
inflammatory ;  the  third  is  intended  to  embrace  those  which 
exhibit  the  lowest  degree  of  febrile  action,  and  the  second  those 
of  an  intermediate  character.  The  first  has  been  again  divided 
into  two  sub-varieties  :  the  idiopathic  wadi  symptomatic.  This 
division  is  another  that  inculcates  a  false  idea,  because  both 
are,  in  truth,  symptomatic.  The  first  is  symptomatic  of  a  re- 
duction of  nervous  irritability  and  a  constriction  of  the  capil- 
lary vessels,  and  the  second,  of  a  pre-existing  inflammation  or 
local  lesion  of  the  solids.  To  distinguish  the  former  from  the 
latter  after  this  explanation,  we  may  use  the  word  idiopathic. 

TREATMENT. 

The  treatment  of  this  form  of  disease  is  very  simple,  as  a 
general  rule,  if  there  be  no  complication  ;  but  it  is  not  always 
practicable  for  the  practitioner  to  determine  immediately  the 
existence  of  a  complication,  hence  the  safer  course  will  always 
be  to  adopt  an  early  treatment. 

The  first  indication  is  to  remove  morbid  accumulations  in 
the  stomach,  and  equalize  the  circulation  and  nervous  action. 
To  fulfill  this,  an  emetic  must  be  administered  as  early  as  pos- 
sible, to  be  followed  by  a  cathartic ;  after  which,  vapor  baths, 
sudorifics,  and  refrigerant  diuretics,  must  be  given,  and  the 
surface  bathed  frequently  with  cold  or  tepid  water.  The  wet 
sheet  may  here  be  used  with  advantage. 


72  FBBRIILE  FORMS   OF   DISEASE,  ETC. 

As  soon  as  the  more  active  inflammatory  symptoms  have 
become  subdued,  tonic  febrifuges  must  be  given  ;  and  here  we 
prefer  our  usual  preparation  of  Sulphate  of  Quinine,  and 
rrussiate  of  Iron,  which  will  generally  overcome  this  form  of 
disease,  except  it  be  complicated,  when  a  course  of  treatment 
must  be  pursued  which  is  adapted  to  the  complication. 

It  will  occasionally  occur,  however,  that  the  inflammatory 
condition  of  the  system  will  continue  very  severe  and  obsti- 
nate, not  readily  yielding  to  the  above  treatment ;  in  such 
cases,  the  Tincture  of  Gelseminum  must  be  employed  every 
hour  until  the  eyelids  begin  to  feel  heavy,  with  scarcely  an 
ability  on  the  part  of  the  patient  to  control  them,  when  its  ad- 
ministration must  be  omitted,  and  no  more  should  be  given 
until  the  efiect  has  entirely  subsided. 

To  remove  the  accumulations,  and  produce  an  alterative 
action,  let  the  Podophyllin,  Leptandrin  and  Jalapin  be  given 
in  sufficient  doses  to  produce  the  desired  result.  If  an  active 
cathartic  is  necessary  at  the  beginning,  increase  the  quantity ; 
when  a  moderate  or  alterative  only  is  necessary,  diminish  the 
dose.  This  course  should  be  maintained  until  the  heavy  coat 
is  removed  from  the  tongue,  as  well  as  the  bad  taste  from  the 
mouth. 

K  the  tongue  indicates  much  gastro-intestinal  irritation,  ca- 
thartics must  be  used  with  great  care ;  in  no  case  persist  in 
their  use  if  vomiting  is  produced  by  the  medicine,  for  it  may 
be  laid  down  as  a  general  rule  in  practice,  that  injury  results 
from  persisting  in  the  use  of  any  irritating  agents. 

The  emetic  when  used  should  be  efficient,  and  as  a  general 
thing  should  be  resorted  to  in  the  very  beginning. 

After  the  emetic  and  cathartic  have  been  used,  and  the 
stomach  freed  from  nausea,  let  the  patient  take  the  Tincture 
of  Veratrum  Yiride  in  as  large  quantities  as  possible  without 
producing  nausea  or  vomiting ;  this,  however,  is  to  be  given 
when  the  pulse  continues  full  and  hard ;  but  if  there  be  any 
inflammation,  or  even  much  irritation  of  the  stomach,  vomit- 
ing will  ensue  at  once ;  then  the  quantity  must  be  reduced,  or 
its  use  discontinued  entirely. 


CHAPTER  V. 


Pyeexia  Sthenica — Simple  Inflammatory  Fever — The  Sy- 
NOCHAL  Grade  of  Ldopathio  Fever  ;  Febris  Yasorum. 

This  form  of  fever  most  generally  seizes  young  persons  in  the 
flower  of  their  age,  and  full  of  blood,  those  who  are  athletic 
and  therefore  fibrous  and  elastic,  finally,  those  who  constitute 
the  first  class  of  organizations.  It  may  occur  at  any  season  of 
the  year,  but  it  is  more  liable  to  prevail  during  the  spring  and 
summer. 

It  begins  with  a  sense  of  lassitude,  the  body  feeling  as  if 
bruised ;  with  weakness ;  cold  and  hot  sensations  which  al- 
ternately succeed  each  other;  with  tremors  and  with  pains  all 
over  the  body,  but  particularly  in  the  shoulders,  back,  knees, 
legs,  and  head.  The  bowels  are  constipated  and  the  secretions 
are  suspended.  As  this  stage  passes  ofi",  the  second  is  intro- 
duced with  an  intense  and  bm-ning  heat,  an  unquenchable 
thirst ;  a  suffusion  of  the  eyes,  a  redness  and  swelling  of  the 
face ;  nausea  ;  vomiting  ;  restlessness  ;  anxiety  ;  a  full,  quick, 
and  strong  pulse  ;  a  dryness  of  the  skin  ;  a  scanty  and  highly 
colored  urine ;  a  rough  and  dry  tongue,  frequently  covered 
with  a  thick  scurf;  the  respiration  is  difficult  and  labored. 
Delirium  is  not  very  common  to  this  form  of  fever,  but  when 
it  does  supervene  it  is  severe  and  threatening  ;  the  acuteness  of 
the  senses  of  seeing  and  hearing  is  much  increased,  and 
finally,  the  blood,  when  drawn,  shows  a  bufly  coat,  cupped 
crassamentum  and  a  deficiency  of  serum  ;  but  the  introduction 
of  this  symptom  is  measurably  useless  to  Eclectics  as  they 
never  see  it,  except,  possibly,  by  some  unexpected  accident. 

It  is  not  uncommon  for  the  preceding  symptoms  to  manifest 
remissions  and  exacerbations — the  first  appearing  in  the  morn- 
ing, and  the  second  in  the  evening,  until  terminated  by  some 
critical  evacuation  and  a  return  to  health  ;  or  by  stupor,  coma, 
ti'emors,  twitching  of  the  muscles,  hiccough,  and  death. 
5 


74  FEBEILE   FOKMS   OF   DISEASE,    ETC. 

This  form  of  fever,  when  its  simple  form  is  maintained, 
very  seldom  continues  beyond  the  ninth  day,  but  it  may  be 
extended  to  the  fourteenth,  and  it  may  conclude  on  the  fifth  or 
seventh.  When  the  symptoms  have  continued  to  increase  in 
violence  to  the  fourth  or  fifth,  a  crisis  may  be  looked  for  on  the 
seventh,  and  when  its  crisis  is  procrastinated  to  the  fourteenth, 
it  will  be  observed  to  increase  in  violence  to  the  ninth  or 
eleventh. 

Prof.  Eberle,  says  that  revolution  in  this  form  of  fever  is 
almost  invariably  attended  by  general  and  iree  perspiration, 
urination,  etc.  As  this  is  one  of  nature's  contrivances,  he  does 
not  seem  to  think  that  the  revolution  is  affected  by  secretion, 
of  which  perspiration  and  urination  are  now  two  of  the  most 
important.  And  here  we  would  have  the  reader  remark  that 
he  and  most  other  authors  inform  us  that  a  reddish  or  pale 
sediment  of  the  urine,  is  a  never  failing  concomitant  in  the 
crisis  of  this  fever.  Is  the  substraction  of  this  sediment  from 
the  blood  a  mere  circumstance,  and  one  of  no  particular  im- 
portance ?  Did  its  retention  in  the  blood  have  no  agency  in 
the  production  of  the  fever  ? 

It  should  be  remembered  that  in  this  form  of  fever  the  chilly 
sensations  during  the  forming  stage,  do  not  appear  to  be  at- 
tended by  any  absolute  reduction  of  temperature,  at  all  events, 
if  such  be  the  fact,  it  is  not  ascertainable  by  the  sense  of 
others,  or  the  thermometer.  The  only  opinion  we  can  suggest 
to  account  for  it  is,  that  the  cold  and  hot  sensations  which  are 
alternately  produced,  are  occasioned  by  alternate  contractions 
and  relaxations  of  the  capillary  vessels  ;  that  in  the  former  no 
caloric  is  evolved,  and  that  in  the  latter  it  is.  In  support  of 
this  view,  it  should  be  remembered  that  the  system  is  now 
struggling  to  remove  all  constriction  and  finally  succeeds. 

In  many  constitutions  of  even  the  firmer  class,  there  is  some 
part  more  feeble  than  the  balance  of  the  system,  and  hence, 
therefore,  more  liable  to  take  on  inflammatory  action  in  the 
progress  of  this  fever,  because  of  its  inability  to  resist  an  ex- 
cessive invasion  of  the  febrile  action.  Hence  it  is  that  the 
simple  and  even  tenor  of  this  fever  is  frequently  complicated 
with  topical  inflammation. 

Causes. — Of  all  the  causes  to  this  form  of  fever,  an  undue 
or  unguarded  exposure  to  cold  is  confessedly  much  the  most 
frequent,  and  in  a  large  majority  of  instances  this  exposure  re- 
sults trom  an  incapacity  to  anticipate  atmospherical  vicissi- 
tudes or  mutations,  and  hence  its  more  frequent  prevalence  in 
the  spring  or  fall  mouths,  more  particularly  in  cold  or  variable 
climates.  When  we  consider  the  fibrous  and  sensitive  charac- 
ter of  those  who  are  most  organically  liable  to  this  form  of 
fever,  we  should  reckon  an  electi-ic  condition  of  the  atmos- 
phere as  a  Irequent  cause,  hence  the  reason  why  northwest  and 


FEBKILE   F0BM8    OF   DISEASE,   ETC.  75 

northeast  winds  so  frequently  occasion  it.  A  sudden  exposure 
to  cold  water  is  said  to  cause  it  when  the  person  is  heated  by 
exercise. 

An  exposure  to  solar  heat,  by  those  of  this  class  who  have 
not  been  accustomed  to  it,  trequeutly  proves  a  successful 
cause.  The  use  of  highly  stimulating  food  and  drink,  is  also 
a  frequent  cause  in  old  and  affluent  communities.  But  in  all 
our  reflections  upon  the  etiology  of  fever,  it  should  be  remem- 
bered that  the  various  grades  and  modifications  of  it  depend 
more,  much  more  upon  the  inherent  organic  conditions  of  the 
system,  than  upon  either  the  remote  or  exciting  cause.  Hence 
we  may  safely  assert  that  aU  the  forms  of  fever  which  are  in- 
cidental to  any  given  section  of  country,  at  the  same  season  of 
the  year,  are  but  so  many  varieties  or  modifications  occasioned 
by  the  existing  differences  that  organically  exist  between  indi- 
viduals. Thus,  while  the  athletic — those  having  large  organs 
of  animal  sensibility  and  muscular  motion,  |will  have  pure 
synocha ;  another  with  less  endowment  of  animal  sensibility, 
synochus  ;'  and  in  a  third,  in  whom  both  of  those  vital  forces 
are  feeble,  a  typhoid,  which,  by  neglect  or  improper  treatment 
may  degenerate  into  a  proper  typhous.  A  sight  of  the  pa- 
tient, therefore,  should  generally  determine  the  grade  of  the 
fever. 

Diagnosis. — It  is  distinguished  from  typhous  fever  by  its 
strong,  high,  full  pulse,  dry  tongue,  intense  thirst  and  heat, 
and  greater  violence  of  the  pains.  The  absence  of  clearly  de- 
fined periodicity,  will  distinguish  it  from  those  forms  which 
constitute  the  next  genus,  and  from  the  succeeding  species  by 
the  diagnosis  which  will  there  be  given. 

Pbognosis. — Such  is  the  vital  resistance  in  synochal  fevers 
that  the  prognosis  should  not  be  considered  as  either  uncertain 
or  unfavorable.  What  the  bleeding,  purging,  and  mercurial 
practice  may  efiect  upon  it,  is  altogether  another  question. 
This,  so  long  as  it  has  no  complications  to  contend  with,  is  the 
least  dangerous  of  all  the  forms  of  continued  fever,  and  for 
the  simple  reason  that  the  vital  powers  are  adequate  to  the  re- 
moval of  the  disease. 

If  the  system,  though  generally  strong,  should  possess  feeble 
parts,  inflammation,  in  some  one  of  them,  may  supervene,  and 
in  such  case,  the  magnitude  of  the  danger  will  depend  upon 
the  functional  importance  of  the  invaded  part.  K  the  breath- 
ing should  become  obstructed  or  painful,  or  attended  with  a 
cougli,  or  with  pain  in  the  thorax ;  or  if  the  abdomen  be  tense 
and  tender  upon  pressure,  we  may  apprehend  danger.  The 
presence  of  mere  delirium  should  not  be  regarded  as  unfavor- 
able, but  should  the  existence  of  violent  pain  in  the  brain  be- 
come indicated,  encephalitis  may  be  suspected  to  exist  and  to 
greatly  increase  the  danger. 


1^6  FEBKILE   FOKMS    OF   DISEASE,  ETC. 

Favokable  Signs. — A  slight  hemorrhage  from  the  nose,  a 
general  perspiration,  urine  pale  when  voided  and  turgid  when 
cool ;  a  reduction  of  the  temperature  and  of  the  hardness, 
quickness,  and  frequency  of  the  pulse. 

Synochus  Fever — Common  Continued  Synochus  Feveb — 
Entekic  Fever — T^^phoid  Miteor — Typhoid  Fever — En- 
TEBO — Mesenteric  Fever,  etc. 

"We  have  thought  it  best  to  regard  this  form  as  a  distinct  spe- 
cies, for  the  reason  that  it  is  confined  to  those  regions  of  the 
country  in  which  the  bilious  or  so-called  miasmatic  forms  of 
fever  do  not  prevail. 

It  is  very  probable  the  several  names,  at  the  head  of  this 
article,  have  been  given  to  one  and  the  same  form  of  disease, 
modified  probably  by  local  and  constitutional  circumstances. 
The  profession,  it  seems,  have  been  brought  to  this  conclusion 
by  the  labors  of  Louis,  who  designated  it  by  the  name  of  ""  ty- 
phoid fever,"  but  its  nomenclature  is  still  unsettled,  and  con- 
sequently we  have  preferred  to  call  it  by  a  name  which  indi- 
cates a  grade  of  action  between  the  highest  and  the  lowest 
that  is  known  to  the  genus.  Dr.  Wood  calls  it  "  euteritic 
fever,"  and  probably  for  the  reason  which  we  infer  from  the 
following  remark  of  his :  "  The  intestinal  afiection  is  as  char- 
acteristic of  this  disease,  as  the  eruption  is  of  small-pox."  We 
can  not  adopt  this  name,  because  it  only  designates  a  specific 
form,  instead  of  a  general  one.  We  conceive  that  fiffy  indi- 
viduals may  have  the  same  grade  of  continued  fever,  and  yet 
no  two  of  them  will  be  attended  by  the  same  local  or  special 
phenomena.  The  multiplication  of  names  to  include  or  ex- 
press local  or  incidental  circumstances,  has  done  much  violence 
to  the  profession. 

We  are  disposed  to  suggest,  in  this  place,  that  the  present 
form  represents  the  general  character  of  this  genus,  and  that 
the  synochal  form  is  an  upward  departure  from  it,  and  that 
the  typhous  is  a  descending  one ;  and  hence  they  should  be 
regarded  as  being  merely  varieties,  and  this  conclusion  is  sus- 
tained by  a  corresponding  condition  of  the  vital  forces  among 
men.  Some  men  are  much  above  the  average  of  society  in 
vital  force,  and  others  are  much  below  it ;  the  average  then, 
is  the  legitimate  sphere  of  the  synochus  grade  of  fever. 
Either  of  the  ascending  forms  of  constitution  may  have  ty- 
phous fever,  because  their  vital  force  may  be  reduced  to  the 
typhous  level  by  previously  debilitating  causes ;  hence  it  is 
that  every  man  in  a  crowded  and  filthy  ship  or  prison  may, 
finally,  die  of  typhous  fever.  But  the  reverse  of  this  can  not 
be  etiected — a  man  of  a  low  grade  of  vital  force  will  never 
have  synochal  fever. 


FBBBILB  FOBMS   OF  DISEASE,   ETC.  77 

Now,  in  that  mass  of  society  which  determines  the  average 
of  the  vital  force,  there  necessarily  exists  many  modifications, 
and  each  epidemic  may  result  from  a  modified  condition  of  the 
atmosphere.  In  one  season,  it  may  have  a  particular  pul- 
monic, nervous,  or  gastro-enteritic  tendency.  Under  these 
views,  we  think  it  best  to  generalize  febrile  forms  of  disease, 
to  the  full  extent  of  practical  advantage. 

This,  or  the  synochus  grade  of  fever,  may  have  the  usual 
forming  stage  or  period  of  fever,  but  it  frequently  gives  very 
little  or  no  premonition  of  its  approach,  and  abruptly  an- 
nounces itself  by  a  chill,  which  may  almost  as  abruptly  termi- 
nate by  the  introduction  of  the  fever  ;  but  most  frequently  it 
is  imperceptibly  merged  or  lost  in  the  fever,  which  so  gradu- 
ally increases  as  to  leave  the  patient  unconscious  of  the  mo- 
ment of  beginning. 

In  some  instances,  again,  the  patient  is  scarcely  conscious 
of  the  existing  chill,  and  the  fever  that  succeeds  is  of  a  very 
mild  grade ;  the  tongue  becomes  white,  the  pulse  more  Ire- 
quent  and  full,  with  a  dry  skin  ;  pain,  more  or  less  severe,  over 
the  eyes ;  urine  diminished  and  highly  colored ;  sleep  dis- 
turbed, and  bowels  constipated.  The  appetite  is  not  always 
arrested.  When  the  afiection  is  of  this  mild  grade,  it  passes 
ofl*  in  a  few  days  by  perspiration  or  diarrhea. 

In  our  cold  and  variable  climates,  the  ordinary  continued 
forms  of  fever  present  various  degrees  of  violence,  from  the 
mild  form  above  described,  to  those  of  cerebral  oppression 
and  fatal  collapse.  Gastro-intestinal  irritation  may  almost  be 
regarded  as  a  pathognomonic  symptom  of  this  form  of  fever, 
and  it  usually  appears  early  in  the  seizure,  by  the  manifesta- 
tion of  nausea,  vomiting,  unpleasant  gastric  sensations,  and 
foul  tongue. 

In  that  form  which  is  most  usually  denominated  continued 
fever,  the  symptoms  are,  from  the  beginning,  of  a  pretty  high 
grade  of  violence.  Beside  a  distressing  degree  of  the  symp- 
toms of  the  forming  stage,  the  exciting  degree  of  the  hot  is 
pregnant  with  threatened  danger.  The  skin  is  hot  and  cov- 
ered with  a  pretty  uniform,  but  slight,  blush  of  red  ;  the  face 
is  flushed,  the  pulse  is  active,  full,  and  frequent ;  the  patient 
is  restless,  and  probably  peevish,  and  apparently  incapable  of 
fixing  his  attention  upon  anything,  except  a  dull,  heavy,  or 
throbbing  pain  in  the  head.  The  urine  is  sometimes  pale,  but 
most  frequently  it  is  red,  and  entirely  destitute  of  sediment. 
The  tongue,  being  white  in  the  beginning  of  the  fever,  be- 
comes, in  its  progress,  dry,  harsh,  and  dark-brown ;  the  bow- 
els, as  usual  in  fever,  become  torpid,  but  the  faeces  continue 
soft,  but  frequently  contra-iudicate  the  presence  of  bile. 

For  six  or  seven  days,  these  symptoms,  with  slight  inter- 
missions and  exacerbations,  continue  about  the  same  ;  but,  in 


7S  '  FEBRILE  FORMS   OF  DISEASE,   ETC. 

the  further  progress  of  the  disease,  cerebral  symptoms  are  apt 
to  supervene,  more  particularly  delirium  at  night.  If  the  vital 
energies  are  capable  of  effecting  a  favorable  termination,  it 
may  be  expected  on  the  eighth  or  ninth  day,  othervsdse  it  will 
pass,  with  more  or  less  rapidity,  into  the  typhous  form  or  into 
collapse,  when  all  the  symptoms  will  become  of  a  very  threat- 
ening character — such  as  delirium,  more  or  less  stupor,  dilated 
pupils,  foul  and  dark-brown  tongue,  hurried  breathing,  pick- 
ing at  the  bed  clothes,  subsultus  tendinum,  and  a  gradually 
sinking  pulse  to  the  close  of  life,  which  may  happen  on  the 
fifteenth  day,  but  it  may  be  procrastinated  two  or  three  days 
longer. 

When  the  cold  stage  has  been  protracted,  and  reaction  es- 
tablished with  difficulty,  we  may  infer  the  existence  of  a  feeble 
vital  force,  and  therefore  we  should  be  prepared  to  expect  a 
rapid  declension  of  the  disease  into  the  typhous  stage,  attended 
with  exhibitions  of  cerebral  disorder  of  no  ordinary  grade — 
such  as  an  aversion  to  light  and  sound,  a  disposition  to  watch- 
fulness, confusion  of  ideas  and  delirium,  which  may  become 
continuous  and  violent.  The  head  is  rolled  from  side  to  side ; 
the  arms  and  feet  are  kept  in  frequent  motion  ;  all  portions  of 
the  body  are  tender  to  the  touch,  and  evanescent  pains  are  felt 
in  various  parts  of  it.  There  is  apt  to  exist,  also,  tenderness 
at  the  epigastrium,  flatulence  and  irritability  of  the  stomach. 
In  this  modification  of  the  disease,  the  pulse  never  becomes 
remarkable  for  tenseness  or  fullness,  and  the  typhous  condi- 
tion of  the  disease  may  be  expected  to  supervene  on  the  fourth 
or  fifth  day,  and  then  we  have  a  reduction  of  some  symptoms, 
and  an  introduction  of  others  of  a  less  favorable  import — the 
delirium  passes  into  a  low  and  muttering  raving — great 
mental  oppression,  and  a  rapid  destruction  of  the  vital 
powers. 

When  synochus  fever  occurs  under  circumstances  of  debility 
arising  trom  poverty  and  depravity  of  living,  such  as  may 
characterize  life  in  a  damp  cellar,  poorly  ventilated  and  warmed, 
with  food  poorly  calculated  to  produce  health,  then  we  have  a 
fever  in  which  the  prodromal  stage  is  much  protracted,  and 
the  hot  one  extended  indefinitely  to  five  or  six  days,  or  proba- 
bly to  as  many  weeks.  The  pulse,  in  activity,  Irequently  con- 
tinues at  very  nearly  the  normal  standard,  but  usually  a  little 
accelerated.  The  appetite  is  absent  or  greatly  impaired,  the 
thirst  is  very  moderate,  the  eyes  are  dull  and  sufliised,  and  the 
patient  drowsy ;  the  tongue  is  white  and  slimy,  the  urine  is 
small  in  quantity  and  pale,  containing,  most  generally,  much 
mucus.  This  form  does  not  necessarily  run  into  the  typhous 
state;  but,  as  it  progresses,  the  pulse  becomes  smaller,  weaker, 
and  more  frequent.  It  may  terminate  favorably  about  the 
seventh  or  ninth  day  by  a  general  diaphoresis,  with  a  slow 


FEBEILE   FORMS    OF   DISEASE,   ETC.  79 

convalescence.  In  the  case  of  a  fatal  termination,  the  event 
will  be  preceded  by  muttering,  subsultus  teudinum,  hiccough, 
and  coma. 

When  those  persons  who  have  been  exposed  so  long  to  those 
influences  which  are  called  miasmatic,  as  to  have  the  nervous 
evstem  more  or  less  enfeebled,  and  the  secretions  more  or  less 
impaired,  become  exposed  to  the  influence  of  cold,  a  common 
cause  of  synochus,  a  modification  of  it  will  be  induced  which 
demands  special  notice.  Beside  the  usual  symptoms  of  the 
prodromal  stage  of  fever  in  general,  we  are  required  to  add  a 
sense  of  distention  and  weight  in  the  stomach,  acid  or  bitter 
eructations,  an  icterode  complexion  of  the  face,  pains  in  the 
abdomen,  constipation  or  a  bilious  diarrhea,  occasionally  chilly 
sensations,  and  a  silent  and  gloomy  disposition  of  mind.  In 
the  hot  stage,  the  pulse  is  but  rarely  over  112,  during  the  first 
several  days,  and  for  the  same  iime  it  is  full,  active,  and  com- 
pressible ;  the  skin  rarely  becomes  very  hot— the  tunica  albu- 
ginea  and  the  whole  surface  of  the  body  become  of  a  jaun- 
diced hue ;  some  moisture  may  be  fi'equently  observed,  during 
the  course  of  the  fever,  about  the  region  of  the  heart,  but  a 
general  perspiration  is  but  rarely,  if  ever,  witnessed  before 
the  final  resolution  of  the  fever.  The  urine  is  small  in  quan- 
tity and  charged  with  bile ;  the  tongue  is  bitter  and  covered 
with  yellowish  slime,  which  becomes  brown  as  the  disease  ad- 
vances, and,  though  moist  in  the  beginning,  it  becomes  dry, 
hard,  and  of  a  brown  color.  Nausea,  vomiting,  and  a  loath- 
ing of  food  always  attend,  with  a  desire  of  drinks,  particular- 
ly of  an  acidulated  character.  In  this  modification  there  is  an 
early  tendency  to  pass  into  the  typhous  form,  consequently  the 
most  prompt  attention  should  never  be  withheld.  The  breath- 
ing is  usually  oppressed  and  attended  with  some  cough  ;  the 
remissions  and  exacerbations  are  quite  apparent.  If  it  shall 
reach  the  typhous  stage,  then  delirium  and  all  the  other  phe- 
nomena that  usually  characterize  this  form  of  fever  will  be 
apt  to  make  their  appearance  by  the  fifth,  seventh,  or  ninth 
day. 

In  the  course  of  this  malady  there  are  certain  symptoms, 
that  occasionally  arise,  which  so  unavoidably  aflect  its  general 
character  as  to  make  it  expedient  that  we  should  notice  them. 

Diarrhea  is  a  frequent  attendant  upon  continued  fever,  but, 
whether  present  or  not,  such  is  the  gastro-enteritic  irritability 
that  the  bowels  are  much  more  easily  operated  upon  by  ca- 
thartic medicines  than  in  other  forms  of  fever ;  and  where  a 
doubt  exists  as  to  the  character  of  the  fever,  this  circumstance 
in  the  opinion  of  Dr.  Wood,  should  have  weight  in  determin- 
ing our  opinion.  He  says,  that  diarrhea  sometimes  precedes  the 
fever,  but  more  frequently  comes  on  during  the  first  tweuty- 
four  hoars,  aad  is  often  procrastinated  to  a  later  period.    The 


80  FEBRILE   FORMS    OF   DISEASE,  ETC. 

evacuations  may  be  only  one  or  two  per  diem,  and  they  may 
be  extended  to  a  dozen  or  more ;  and  what  is  equally  if  not 
more  remarkable,  they  have  a  normal  or  healthy  appearance, 
except  as  to  consistency.  As  this  peculiarity  attends  through- 
out the  disease,  it  becomes  one  among  the  best  of  the  diag- 
nostic symptoms,  and,  furthermore,  the  liquidity  of  this  excre- 
tion being  common  to  this  form  of  fever,  marks  it  as  one  of  the 
most  obstinate,  and  therefore,  dangerous  forms  of  fever  we 
have  to  contend  with.  It  prevents  that  concentration  of  the 
vital  force  which  is  indispensable  to  the  i-e-establishraent  of 
depuration.  The  disease  is  sometimes  attended,  particularly 
in  its  advanced  stages,  by  dark-colored  or  even  black  stools — 
sometimes  by  such  as  indicate  the  presence  of  inflammation, 
and  abdominal  pains  are  not  unfrequent  attendants. 

Tymjpanites. — Dr.  Wood  states  that  he  has  scarcely  wit- 
nessed a  case  of  this  fever  in  which  this  symptom  did  not  more 
or  less  prevail.  It  does  not  become  very  obvious  until  about 
the  seventh  day,  but  sometimes  it  obtains  as  early  as  the  third. 
Its  violence  is  usually  proportioned  to  that  of  the  disease. 
Sometimes  the  abdominal  distention  occasioned  by  it  is  veiy 
distressing — it  greatly  interferes  with  the  respiratory  function. 
It  appears  to  be  mostly  confined  to  the  large  intestines. 

Itose-coloi'ed  ei'upiion  is  said  to  be  very  characteristic  of 
this  form  of  fever.  It  occurs  most  frequently  between  the  sev- 
enth and  fifteenth  day,  and  first  appears  on  the  abdomen,  from 
which  it  extends  to  the  breast  and  inferior  extremities.  It  ap- 
pears in  small,  red  spots,  either  round  or  oval,  and  about  a 
line  in  diameter,  more  or  less,  and  possess  a  slight  elevation 
which  disappears  upon  pressure,  and  returns  upon  its  removal. 
Their  number  is  sometimes  only  two  or  three,  but  in  many  in- 
stances they  are  innumerable.  By  appearing  in  successive 
crops,  they  occupy  a  period  ranging  from  three  to  fifteen  days. 
They  are  said  to  be  very  rarely  absent.  They  are  easily  dis- 
tinguished from  petecchise,  which  consists  of  extravasated 
blood  in  the  skin. 

Sudamina. — This  consists  of  vesicles  not  larger  than  a  pin's 
head,  and  in  order  of  time  their  appearance  is  subsequent  to 
that  of  the  rose-colored  eruption.  They  are  more  readily  felt 
than  seen,  unless  viewed  obliquely.  They  may  spread  over 
the  entire  surface,  except  the  face,  but  they  are  more  usually 
confined  to  the  neck  and  the  superior  portions  of  the  chest. 
They  have  but  little  diagnostic  weight,  as  they  occur  in  other 
forms  of  fever,  and  by  no  means  constant  in  any. 

Cough  and  hronchial  rales. — Dr.  Wood  says,  that  "  this  is 
a  very  common  complaint,"  and  that  the  "  cough  is  either  dry 
or  attended  with  a  slight  mucous  expectoration,  with  very  lit- 
tle or  no  soreness  or  sense  of  oppression  in  the  chest.  The  dry, 
sonorous,  and  sibilant  rales  may  be  heard  more  or  less  exten- 


FEBKILE    FORMS    OF   DISEASE,  ETC.  81 

sively  over  the  thorax,  and  are  much  greater  in  proportion  to 
the  amount  of  oppression  or  dyspnoea  than  in  ordinary  ca- 
tarrhal aflections.  They  thus  afibrd  an  important  diagnostic 
sign.  They  are  not,  however,  present  in  all  cases.  Sometimes 
they  begin  with  the  disease,  but  more  frequently  not  until  the 
lapse  of  about  a  week.  Occasionally  they  give  place  to  a 
crepitant  or  sub-crepitant  rale,  indicating  the  occurrence  of 
inflammation  in  the  parenchyma  of  the  lungs." 

Pulse. — This  source  of  information  to  the  vascular  condi- 
tion of  all  forms  of  disease  betrays  much  variety  in  this  form 
of  fever.  It  presents  great  diversity  of  character  in  dif!'erent 
cases  ;  sometimes,  in  the  early  stages,  it  is  full  and  strong, 
and  sometimes  feeble  from  the  outset,  and  always  becomes  so 
in  the  progress  of  the  malady.  But  that  average  pulse,  which 
is  most  characteristic  of  this  fever,  is  one  of  frequency,  small- 
ness,  and  feebleness,  and  is  indicative  of  nervous  irritability 
and  capillary  congestion.  Its  general  range  of  beat  is  Irom 
110  to  160 ;  the  former  marks  the  beginning  and  the  latter  its 
last  stage.  When  the  system  passes  into  a  prostrate  condi- 
tion, its  frequency  is  reduced  below  the  standard  of  health. 

Hemori'hage. — In  the  early  stage  of  the  disease  epistaxis  is 
not  an  unfrequent  phenomenon — the  result,  perhaps,  of  an  ac- 
tive determination  to  the  head  ;  it  is  generally  slight,  though 
sometimes  requires  attention.  In  the  advanced  periods  of  the 
disease,  hemorrhage  from  the  bowels  is  apt  to  supervene,  and 
as  it  is  passive  it  may  be  always  accounted  a  dangerous  indi- 
cation. 

Dullness  or  Hebetude. — In  the  early  and  probably  most  con- 
gested period  of  the  disease,  the  countenance  of  the  patient 
becomes  as  it  were  a  blank — he  is  apathetic  and  low-spirited. 
This  dullness  may  increase  with  the  disease,  until  stupor  and 
even  coma  may  supervene. 

Deliriura. — This  usual  attendant  upon  continued  fever  may 
appear  early  in  the  disease,  but  it  is  usually  procrastinated 
until  about  the  seventh  day.  The  manifestations  of  this  condi- 
tion of  the  brain,  embrace  every  possible  conception  of  which 
the  mind  is  capable.  They  constitute  a  field  of  much  study 
and  interest  to  the  phrenological  physician.  The  peculiarities 
of  the  delirium  are  always  in  harmony  with  the  prevailing  en- 
dowments of  the  brain.  The  strongest  feelings  or  most  gov- 
erning trains  of  thought  are  pretty  certain  to  be  exhibired. 
When  the  vital  and  lower  animal  faculties  are  strong,  the  de- 
lirium may  be  furious  ;  if  caution  be  strong  and  hope  small, 
it  will  be  of  a  desponding  character  ;  if  the  social  sentiments 
be  well  endowed,  the  patient  will  betray  great  pleasure  in  his 
vivid  conceptions  of  the  beautiful  and  the  agreeable ;  and  if 
he  has  much  language  in  connection  therewith,  he  will  proba- 
bly write  poetry  on  the  wall,  or  recite  it  to  his  attendants.  We 


83  FEBRILE    FOKMS    OF   DISEASE,  ETC. 

once  attended  an  unlettered  but  a  very  philosophical  man — 
who  was  organically  a  philosopher.  During  his  fever,  he  ap- 
peared to  find  exceeding  pleasure  in  the  solution  of  philosoph- 
ical questions. 

But  this  state  of  mental  exuberance  is  not  of  long  continu- 
ance— it  passes  very  frequently  into  a  muttering  of  broken 
sentences,  and  thence  into  stupor,  and  finally  coma.  It  ia 
proper  to  add  furthermore,  that  there  are  two  varieties  of  de- 
liriam  in  this  fever — one  results  Irom  an  active  cerebral  circu- 
lation, in  fibrous  constitutions,  and  the  other  from  cerebral  irri- 
tation, resulting  from  an  insufficient  circulation — debility.  It 
may  be  further  remarked,  that,  with  the  remissions  and  ex- 
acerbations, these  two  forms  of  delirium  may  alternate  each 
other. 

Sloughing  of  the  sJcin. — The  physician  should  be  constantly 
on  the  watch  to  prevent  this  liability  ii"om  running  into  serious 
mischief.  Vesicated  portions  of  the  skin  and  those  upon  which 
the  patient  constantly  reposes  his  weight,  are  very  apt  to 
slough.  The  knowledge  of  this  tendency  should  greatly  di- 
rect our  indications  of  treatment — diminished  vitality,  and 
consequently  a  feeble  capillary  circulation. 

Retention  of  urine. — The  accumulation  of  urine  in  the  blad- 
der sometimes  becomes  very  considerable  —  the  distention 
occasioned  in  this  way  has  sometimes  been  enormous.  The 
possibiJity  of  this  occurrence  should  keep  the  physician  ad- 
monished of  his  duty  in  this  respect.  "  M.  Marten  Solon," 
says  Dr.  Wood,  "  has  paid  special  attention  to  the  state  of  the 
urine  in  this  disease.  He  has  found  it  to  be  more  scanty, 
higher  colored,  and  denser  than  in  health,  equally  acid,  if  not 
more  so,  much  more  abundant  in  urea,  and  occasionally  allu- 
minous,  especially  in  severe  cases,  in  which  this  character  of 
secretion  must  be  considered  as  an  unfavorable  sign." 

We  have  now  passed  over  those  symptoms  which  more  or 
less  frequently  obtrude  themselves  upon  this  form  of  disease, 
if  not  absolutely  essential  to  it.  As  they  are  well  calculated 
to  keep  up  the  vigilance  of  the  physician,  we  could  not  con- 
sent to  omit  them. 

Causes. — Upon  this  subject  there  prevails  much  more  spec- 
ulation than  knowledge.  It  is  known  that  cities,  prisons,  hos- 
pitals, camps,  and  ships  are,  perhaps,  more  frequently  visited 
by  it  than  other  situations  ;  but  it  is  by  no  means  peculiar  to 
them,  for  it  has  fatally  prevailed,  as  an  epidemic,  in  the  heal- 
thiest regions  of  our  country.  It  is  known,  furthermore,  that 
those  who  are  under  the  meridian  of  life  are  much  more  liable  to 
it  than  those  who  are  above  it.  Dr.  Wood  says,  that  "  of  255 
cases  observed  by  Louis  and  by  Chomel,  78  were  from  fifteen 
to  twenty  ;  95,  from  twenty  to  twenty-five ;  54,  from  twenty- 


FEBEILB    FOKMS   OP  DISEASE,  ETC.  83 

five  to  thirty ;  22,  from  thirty  to  forty  ;  5,  from  forty  to  fifty, 
and  only  one  above  fifty." 

These  statistics  have  induced  the  general  opinion  that  the 
aged  are  less  liable  to  it  than  the  youthful ;  but  as  to  the  rea- 
son why  this  is  the  fact,  no  one  seems  ever  to  have  ventured 
an  opinion.  Having  pretty  fully  explained  such  facts  in  the 
second  book,  we  will  just  remark  here  for  the  purpose  of  call- 
ing attention  to  it,  that  the  least  viable  are  the  most  liable  to 
be  cut  down  first.  No  one  ever  died  at  twenty-five,  who  had 
the  vitality  of  those  who  are  now  living  at  the  age  of  eighty- 
five  years.  We  are  willing  to  admit,  however,  that  the  two 
extremes  of  life  are  less  liable  to  it,  than  that  period  which  is 
the  most  distinguished  for  animal  sensibility  and  vascular 
action. 

It  has  been  thought  to  be  contagious,  but  the  weight  of  pro- 
fessional opinion  is  now  opposed  to  such  a  conclusion.  Dr. 
Wood  has  advanced  an  opinion  which  gives  direct  support  to 
those  expressed  by  us,  in  defining  the  constitutional  diflerence 
between  this  and  other  forms  of  continued  fever;  but  the 
reader  would  scarcely  notice  the  correspondence,  without  a 
special  call  of  his  attention  to  it,  because  there  is  no  similitude 
in  the  modes,  respectively,  of  reaching  the  same  fact.  He 
says  : 

"  On  the  whole,  the  most  rational  view  of  the  etiology  of 
enteric  fever,  in  the  present  state  of  our  knowledge,  seems  to 
to  be,  that  an  inherent  predisposition  to  this  disease  exists  in 
many  persons,  analogous,  in  some  measm-e,  to  the  tuberculous, 
the  gouty,  and  the  rheumatic  predisposition,  which  is  liable 
to  be  called  into  action  by  various  exciting  causes,  perhaps  by 
almost  any  cause  capable  of  considerably  disturbing  the  vital 
functions,  but  that  all  persons  do  not  have  the  predisposition, 
and  that  it  is  generally  exhausted  by  one  attack  of  the 
disease." 

If,  now,  the  word  predisposition,  in  the  preceding  quotation, 
be  replaced  by  the  word  liability,  then  the  agreement  between 
us  becomes  obvious  ;  with  this  difierence :  we  have  exposed  the 
organic  conditions  upon  which  the  liability  depends,  while  he 
has  not  and  can  not  show  upon  what  a  predisposition  depends. 
We  have  shown  that  a  predisposition  is,  absolutely,  disease — 
a  conclusion  which  he  would  not  ^rant,  and  yet  it  is  one  which 
be  can  not  avoid. 

Nature. — Authors  have  given  us  nothing  on  this  subject 
which  we  are  willing  to  honor  with  the  epithet  of  resectable 
nonsense.  Many  have  labored  to  find  some  sort  of  inflamma- 
tion in  some  sort  of  a  place  in  which  to  found  it ;  but,  as  yet, 
they  have  so  utterly  failed,  as  to  cause  Dr.  Wood  to  conclude : 
"  As  to  the  real  nature  of  the  fever,  we  are  in  the  dark,  as  we 
are,  in  fact,  in  relation  to  aU  the  essential  fevera." 


84 


FEBRILE   F0EM8    OF  DISEASE,     ETC. 


We  are  of  opinion  that  fever  is  as  easily  understood  as  in- 
flammation, and  that  it  is  as  comprehensible  as  any  other  vital 
action ;  and  as  to  the  ultimate  nature  of  any  one,  we  neither 
know  nor  can  know  anything.  Fever,  in  every  instance,  must 
hold  a  precise  relation  to  the  character  of  the  disturbing  ob- 
struction and  the  organization  its  acts  upon,  and  the  mode  of 
its  action. 

Diagnosis. — It  should  always  be  remembered  by  the  attend- 
ing physician,  that  all  febrile  forms  have,  in  the  beginning,  so 
strong  a  family  likeness  that  it  is  exceedingly  difficult,  if  not 
impossible,  to  distinguish  one  from  another ;  consequently,  no 
attempt  should  be  made  at  diagnosis  for  the  first  three  or  four 
days.  If  an  epidemic  prevail,  he  will  be  justified,  in  the  be- 
ginning, in  treating  it  as  one  of  the  same  form.  After  the 
lapse  of  three  or  four  days,  the  soft,  or  even  the  semi-fluid 
character  of  the  faeces,  the  insidious  character  of  the  attack, 
the  gloomy  expression  of  the  countenance,  the  cough,  the  rose- 
colored  eruption,  the  tympanitic  abdomen,  the  sudoraina,  the 
retention  of  urine,  and  the  pulse  will  distinguish  it  from  other 
forms  of  continued  fever.  From  remittent  fever,  it  may  be 
distinguished  by  the  less  marked  character  of  its  remissions. 
When  remittent  fever  assumes  the  typhoid  character,  the  di- 
agnosis will  become  obscure,  and  of  but  little  importance  if 
made.  The  diagnosis  between  it  and  typhous  will  be  presented 
when  we  treat  of  the  latter. 

Prognosis. — When  this  form  of  fever  is  allowed  to  run  its 
course,  without  becoming  complicated  with  local  inflamma- 
tion, it  should  never  be  accounted  dangerous,  but  as  one,  par- 
ticularly under  a  proper  treatment,  disposed  to  terminate 
favorably  by  a  diaphoresis  at  some  time  within  the  period  of 
two  weeks.  But  sometimes  the  constitutional  infirmities  do 
not  permit  of  such  a  result,  and  then  we  find  the  pulse  -weak, 
small,  and  ti-equent,  the  muscular  system  greatly  prostrated, 
and  a  constant  disposition  of  the  patient  to  lie  upon  his  back, 
all  of  which  denote  a  collapse,  from  which  recovery  is  scarcely 
ever  to  be  expected,  and  more  particularly  if  complicated  with 
inflammation,  which  is  most  generally  the  case.  Under  such 
circumstamces,  the  prognosis  is  always  unfavorable. 

Indications. — In  this  form  of  fever,  nothing  more  appears 
to  be  required  than  to  remove  the  constriction,  to  equalize  the 
circulation,  and  to  sustain  these  achievements  when  gained  by 
a  proper  alterative  couree. 

Treatment. — At  the  commencement  of  this  disease,  we  pre- 
fer the  use  of  anti-periodics,  anodyne,  and  diaphoretics,  for  the 
purpose  of  allaying  nervous  irritability,  equalizing  the  circu- 
lation, and  thereby  removing  constriction.  If,  however,  diar- 
rhea should  be  present,  or  an  extreme  susceptibility  to  such 
condition,  it  will  be  proper  to  commence  the  treatment  with 


FEBKILE   FORMS   OF   DISEASE,    ETC.  85 

mild  evacnants,  such  as  the  Compound  Powder  of  Rhubarb 
and  Potassa,  or  the  syrup  of  the  same,  in  doses  of  five  or  ten 
grains  of  the  powder,  or  a  fluid  drachm  of  the  syrup,  to  be  re- 
peated every  two  hours,  and  continued  until  the  bowels  are 
thoroughly  evacuated,  and  the  diarrheal  disposition  removed 
or  lessened.  Occasionally,  when  hepatic  fever  is  present  to  a 
considerable  extent,  we  prefer  the  following  preparation : 

R.         Podophyllin,  grs.  ij, 
Caulophyllin, 
Leptandrin,  da  grs,  vi, 
Comp.  Powder  of  Ipecac,  and  Opium,  grs.  xvi.  Mix, 

Divide  into  four  powders,  and  administer  one  every  four  hours, 
until  catharsis  of  a  bilious  character  is  produced.  This  com- 
pound may  likewise  be  used  in  cases  where  the  diarrhea  is  ac- 
companied with  watery  evacuations  and  much  pain. 

After  having  accomplished  the  results  to  be  desired  from  the 
above  agents,  it  becomes  necessary  to  administer  the  anti-pe- 
riodic and  diaphoretic  agents  at  first  referred  to ;  the  most  efli- 
cacious  combination  we  have  found  to  be  as  follows  : 

R.         Sulphate  of  Quinine,  grs.  xx, 

Ferro-Cyanuret  of  Iron,  grs.  xv, 
Cornin,  grs,  xviii, 
Hydrastin,  grs.  xx.     Mix, 

Divide  into  ten  powders,  and  give  one  every  four  hours,  in 
any  convenient  vehicle,  and  it  may  be  continued  throughout 
the  disease,  if  not  subsequently  contra-indicated,  even  dm'ing 
the  stage  of  convalescence. 

In  connection  with  this  powder,  and  for  the  purpose  of  pro- 
moting diaphoresis,  the  Compound  Powder  of  Ipecac,  and 
Opium  must  be  given  in  doses  of  from  three  to  five  grains, 
thi-ee  or  four  times  a  day;  this,  however,  must  be  omitted 
should  there  be  pain  in  the  head  or  a  determination  thereto. 

In  every  case  of  this  fever,  throughout  its  whole  course,  es- 
pecial attention  must  be  bestowed  upon  the  surface.  It  should 
be  bathed  as  often  as  two  or  three  times  a  day  with  a  cold  al- 
kaline wash,  and  even  more  frequently,  should  the  heat  obsti- 
nately continue.  The  patient  may  drink  freely  of  cold  water 
throughout  the  whole  course  of  ttie  disease,  and  if  he  desires 
it,  a  piece  of  ice  may  be  given  him.  By  a  perseverance  in 
this  treatment,  the  disease  will  generally  yield  in  from  three 
to  eight  days. 

In  the  progress  of  this  fever,  many  symptons  of  a  local 
character  may  present  themselves,  demanding  the  prompt  in- 
tertbrence  of  the  practitioner.  Tlie  diarrhea  may  not  give  way 
to  the  above  treatment,  but  may  continue  with  much  severity, 


86  FEBKILE   FORMS   OF   DISEASE,  ETC. 

rapidly  debilitating  the  patient ;  in  this  case,  astringents  mnst 
be  given,  and  we  prefer  the  addition  of  from  five  to  eight 
grains  of  Geranin  to  each  dose  of  the  above  Rhubarb  and 
Potassa  preparations,  to  any  other  agent  with  which  we  are 
acquainted. 

Tympanitis  is  a  common  occurrence  and  must  always  be 
treated  with  warm  fomentations,  emollient  cataplasms,  and 
counter-irritants,  together  with  the  means  heretofore  named 
for  this  local  difficulty.  If  it  should  obstinately  continue,  with' 
constipation,  the  injections  referred  to  in  another  part  of  this 
work,  must  be  often  repeated  with  laxative  doses  of  Seidlitz 
Powders. 

Cough  is  sometimes  present,  and  may  be  relieved  by  the 
use  of  equal  parts  of  the  Syrup  of  Squills,  Syrup  of  Senega, 
and  Camphorated  Tincture  of  Opium,  and  of  which  one  or 
two  fluid  drachms  may  be  administered  every  three  or  four 
hours.  If  it  proves  severe  and  unyielding,  Mustard  Poultices 
must  be  applied  over  the  chest. 

Hemorrhage  frequently  occurs  in  this  disease  ;  when  mod- 
erate it  is  not  alarming,  but  becomes  so  when  excessive.  It 
must  be  met  by  the  continued  use  of  tonics  and  astringents ; 
and  if  it  be  excessive  epistaxis,  it  may  be  become  necessary  to 
plug  the  nostrils  with  sponge,  moistened  and  dipped  in  pow- 
dered Tannin. 

Under  the  old  depletive  system  of  medicine,  the  condition 
of  the  blood  and  of  the  nervous  power  becomes  so  changed  by 
the  treatment,  that  this  symptom  is  not  an  unfrequent  attend- 
ant ;  while,  under  the  Eclectic  practice,  in  which  the  integrity 
of  the  system  is  maintained  throughout  the  whole  course  of 
the  disease,  the  corpuscles  of  the  blood  being  increased,  and 
the  nervous  system  invigorated,  it  is  seldom  met  with. 

Should  there  be  excessive  determination  to  the  head,  as  man- 
ifested by  pain,  or  delirium,  or  both,  cold  applications  must 
be  applied  to  the  head,  with  counter-irritation  to  the  back  of 
the  neck,  as  the  application  of  Mustard  Poultices  ;  and  the  in- 
ferior extremities  must  be  kept  very  warm  by  bathing  in  hot 
water,  application  of  bottles  of  hot  water,  or  other  similar 
means. 

When  retention  of  urine  occurs,  warm  fomentations  of  bit- 
ter herbs  applied  over  the  pubes,  with  diuretics  internally.  wiU 
generally  prove  sufficient.  The  diuretic  preparation  which  we 
most  commonly  employ  is  Spirits  of  Niter,  given  in  hulf- 
drachm  doses,  every  hour  or  two,  in  Spearmint  tea,  or  decoc- 
tions of  Marsh  Mallows,  or  Uva  Ursi.  This  treatment  is  re- 
commended where  sensibility  exists,  as  evinced  by  pain  ;  but 
as  this  symptom  frequently  occurs  without  pain,  the  practi- 
tioner must  be  watchfal  of  it,  and  in  such  instances  introduce 
the  catheter. 


FEBRILE   FORMS    OF   DISEASE,  ETC.  87 

In  the  advanced  stages  of  the  disease,  when  there  is  debility, 
with  stupor  and  delirium,  stimulants  must  be  given,  and  con- 
tinued, until  the  solution  of  the  disease,  and  until  convales- 
cence has  ensued ;  wine  whey,  Longworth's  Catawba  wine, 
porter,  and  even  brandy  may  be  administered  at  intervals  with 
excellent  effect.  Sulphuric  Ether  is  often  efficacious  in  cases 
of  sudden  and  great  prostration.  The  temperature  of  the  sys- 
tem must  also  be  regulated  as  much  as  possible,  by  the  appli- 
cation of  sinapisms,  hot  bricks,  or  bottles  of  hot  water,  etc., 
kept  constantly  to  the  feet  and  legs,  and  cold  or  cooling  washes 
applied  to  the  head.  Excessive  stimulation  to  the  lower  ex- 
tremities must  be  avoided,  lest  sloughing  should  take  place. 
If  the  como  or  delirium  be  obstinate,  the  hair  may  be  cut  or 
shaved  off,  and  the  cooling  washes  continued. 

The  diet  of  the  patient,  in  the  early  part  of  the  disease, 
should  be  very  light  and  usually  of  a  liquid  character,  as  toast- 
water,  solution  of  Gum  Arabic,  rice-water,  weak  Indian-meal 
gruel,  together  with  the  juice  of  sweet  grapes  and  oranges. 

As  drinks,  coUl  water,  cold  lemonade,  or  infusions  of  bitter 
herbs  may  be  allowed.  In  the  stage  of  prostration,  animal 
broths,  beef  or  mutton  tea,  milk  punch,  and  other  stimulating 
nutriment  must  be  given  to  sustain  the  patient's  strength. 

The  room  should  be  trequently  ventilated,  and  the  clothing 
changed  at  least  as  often  as  every  other  day. 

During  convalescence,  the  diet  should  be  mild,  nutritious, 
and  easy  of  digestion — care  being  taken  that  the  patient  does 
not  indulge  too  freely,  or  use  indigestible  food,  lest  sudden  dis- 
solution should  happen. 

TYPHOUS     FEVER TTPIIUS     GRAVIOR SPOTTED     FEVER PETEG- 

CniAL     FEVER PUTRID    FEVER CAMP     FEVER SHIP    FEVER 

JAIL   FEVER HOSPITAL    FEVER. 

In  our  treatment  of  febrile  forms  of  disease,  we  shall  ob- 
serve the  distinctions  which  have  been  made  by  Dr.  Wood. 
The  words  typhous  and  typhoid  will  be  used  as  adjectives  to 
express  that  resemblance  of  typhous  fever,  which  other  forms 
of  fever  sometimes  assume ;  while  typhus  will  be  used  as  a 
substantive  or  as  a  name  to  designate  a  special  form  of  fever — 
that  which  has  been  denominated  typhus  gravior,  spotted  fe- 
ver, ship  fever,  etc. 

When  treating  of  synochus  or  typhoid  fever,  we  gave  it  as 
our  opinions  that  syiiocha,  synochus,  and  typhus  were  but 
three  varieties,  but  the  differences  between  them  are  such  as 
to  have  caused  them  to  be,  by  almost  all  writers,  treated  of  as 
three  pretty  distinctly-marked  forms  of  febrile  disease.  We 
have,  therefore,  arranged  them  as  species,  more  especially  as 
there  exists  many  intermediate  shades  of  difference  between 


88  FEBKILE   FOEMS    OF   DISEASE,    ETC. 

the  three,  which  constitute  varieties.  This  arrangement,  as  we 
have  before  remarked,  has  its  parallel  in  the  three  grades  of 
vital  strength  that  distinguishes  society.  To  the  v^^ord  predis- 
position, we  can  attach  no  idea  independently  of  an  obvious 
organic  condition — as  an  abstraction,  it  conveys  no  idea,  ex- 
cept that  of  the  fact — the  patient  has  a  fever  or  is  liable  to  it ; 
and  of  this  liability  it  conveys  no  instruction.  But  the  liabil- 
ity of  one  to  a  particular  form  of  disease  is  indicated  by  an 
observable  peculiarity  of  organization,  and  thus  our  idea  is 
rendered  intelligible  and  instructive. 

Dr.  Wood  says :  "  There  are  undoubtedly  strong  resem- 
blances between  certain  cases  of  the  enteritic  (synochus)  and 
typhous  fevers ;  and  though  in  most  cases  easily  distinguished 
by  the  obvious  symptoms,  they  were  often  confounded,  until 
the  work  of  Louis  placed  us  in  possession  of  the  means  of  a 
more  accurate  diagnosis."  He  continues:  "But  it  is  highly 
probable  that  the  two  diseases  are  sometimes  combined,  in 
consequence  of  the  simultaneous  character  of  their  causes." 

This  conclusion  we  very  seriously  doubt.  It  is  very  proba- 
ble that  the  two  causes  could  make  equally  strong  impressions 
upon  the  same  system  at  the  same  time  ;  and  it  is  equally  im- 
probable that  two  forms  of  disease  could  possess  the  system  at 
the  same  time  ;  but  we  can  readily  admit  that  two  causes  ca- 
pable of  producing,  by  their  joint  action,  a  modification  of  ob- 
struction, might  produce  a  modified  form  of  fever. 

But,  whatever  may  be  the  cause  or  causes  of  typhous  fever, 
we  exceedingly  doubt  their  capacity  to  produce  it  in  one  of  a 
vigorous  vital  force — a  strongly-reactive  force,  unless  it  has 
the  power  to  sti'ike  with  death,  as  it  were,  the  irritability  of 
the  nervous  system.  The  history  of  the  disease  shows  that 
persons  in  comparatively  good  health  have  been  suddenly 
deuly  stricken  with  the  disease  ;  but  of  the  condition  of  their 
vital  force,  normally,  we  have  had  no  information. 

If,  however,  the  cause  has  this  power^  then  this  form  of  fever 
is  distinct,  and  also  independent,  in  a  great  measure,  of  all 
vital  conditions.  It  is  probably  well  known  that  when  a  ty- 
phous epidemic  prevails,  all  other  forms  of  disease  betray  a 
tendency  to  fall  into  the  same  type,  just  as  we  have  recently 
known,  under  an  Asiatic  cholera  atmosphere,  all  other  forms 
of  disease  assumed  more  or  less  that  of  cholera.  With  these 
speculations,  which  are  always  justifiable  in  the  absence  of 
knowledge,  we  proceed  to  the  symptoms  of  typhous  fever. 


CHAPTER  YI. 


Symptoms. — An  intense,  pungent  and  remitting  heat  of  the 
surface ;  a  tense,  low,  quick,  and  unequal  pulse ;  extreme 
weakness;  vast  anxiety  and  dejection  of  mind,  presaging 
everything  that  is  bad ;  nausea,  and,  in  malignant  cases,  a 
vomiting  of  black  bile ;  pain  in  the  temples  and  over  the 
brows,  a  deep-seated  pain  in  the  eyes,  and  a  great  injection  of 
them ;  a  sort  of  smoke-dried  complexion  ;  ringing  in  the  ears ; 
a  laborious  respiration,  interrupted  with  sighs  ;  pain  in  the 
stomach,  limbs,  and  back ;  a  difficulty  in  lying  down  ;  tre- 
mors ;  delirium ;  the  tongue  at  first  white,  afterward  black 
and  dry ;  the  lips  and  teeth  are  lined  with  a  viscid  sordes ; 
an  unquenchable  thirst ;  a  bitter  taste  in  the  mouth  ;  the 
urine,  at  first,  pale,  but  as  the  disease  increases,  extremely 
high-colored,  and  in  some  very  putrid  cases,  it  assumes  a 
blackish  color  and  deposits  a  stool-like  sediment ;  fetid  sweats, 
which  are  sometimes  tinged  with  blood  ;  stools,  highly  ofien- 
sive,  livid,  black,  or  bloody ;  small,  livid  spots  on  the  skin, 
like  flea-bites,  called  petecchise,  or,  if  more  extended,  vibices, 
hemorrhages,  aphthae,  ulceration  of  the  fauces,  and  hiccoughs. 

We  have  presented  a  dense  group  of  fearful  symptoms,  and 
for  the  purpose  of  their  elucidation  a  few  words  of  comment 
and  explanation  will  not  be  out  of  place. 

The  initial  stage  greatly  varies  in  both  degree  and  duration  ; 
it  is  in  some  instances  so  slight  as  scarcely  to  be  observed,  but 
in  others  it  is  severe  and  protracted  ;  the  skin  is  pale,  cold, 
and  shrunken  ;  the  expression  is  peculiarly  anxious  ;  the  pulse 
is  very  feeble ;  and  so  great  is  the  prostration,  that  reaction 
does  not  become  established ;  but  this  extreme  prostration  is 
by  no  means  a  general  feature  of  the  disease.  The  hot  stage, 
in  the  beginning,  manifests  no  considerable  departure  from 
what  is  common  to  other  forms  of  fever. 

We  have  named  nausea  and  vomiting  among  the  symptoms, 
neyertheless  they  are  not  common — frequently  entirely  absent, 
1 


90  FEBEILH   FOEMS    OF   DISEASE. 

and  the  bowels  are  generally  costive.  This  marks  a  diagnos- 
tic difference  between  this  and  the  synochns  fever,  and  we 
regard  it  as  a  more  favorable  symptom.  The  temperature  of 
the  skin  ranges  from  100  to  109  degrees,  and  the  pulse  from 
100  to  160  beats  in  a  minute ;  the  respiration  is  also  very 
hurried,  and  an  exacerbation  usually  becomes  manifest  toward 
night,  with  a  remission  in  the  morning. 

The  disease  having  now  been  at  its  zenith  for  several  days, 
its  characteristic  eruption  then  appeal's  —  that  which  original- 
ly gave  to  the  disease  the  name  of  petecchial  fever.  This 
eruption  is  confined  to  no  particular  portion  of  the  body — it 
may  be  quite  local,  and  it  may  be  so  general  as  to  impart  to 
the  surface  a  measled  appearance.  It  may  or  may  not  be 
slightly  elevated,  and  in  color  it  may  vary  trom  red  to  black, 
as  the  disease  progresses  toward  a  malignant  condition.  The 
eruption  appears  usually  ft-om  the  fifth  to  the  eighth  day,  but 
it  may  anticipate  two  or  three  days,  or  procrastinate  four  or 
five.  Occasionally  they  disappear,  and  then  reappear,  and 
sometimes  they  are  complicated  with  sudamina. 

The  tongue  takes  on  a  brownish  color,  is  more  or  less  dry, 
particularly  in  the  middle  ;  in  many  cases  a  dark  sordes  col- 
lects on  the  teeth,  gums,  and  lips.  It  happens  sometimes,  as 
in  the  typhous  stage  of  other  fevers,  that  the  tongue  is  clean 
and  glossy,  and  finally  comes  to  resemble  raw  beef.  The 
appetite,  in  many  cases,  is  totally  lost,  but  the  loathing  of 
food  is  less  than  it  usually  is  in  more  active  fevers.  The  color 
of  the  face  becomes  of  a  dark-red  or  of  a  livid  hue ;  the  eyes 
become  turbid  ;  some  hemorrhage  is  apt  to  take  place  from  the 
nose,  and  a  peculiar  odor  exhales  from  the  skin. 

As  the  disease  advances,  its  characteristic  stupor  increases, 
so  that  the  patient  ceases  to  notice  anything  that  is  going  on 
about  him,  and  not  unfrequently  delirium  is  complicated  with 
the  stupor.  So  powerless  is  the  circulatory  system,  that  the 
slightest  exertion  is  attended  with  syncope ;  great  thoracic 
oppression  not  unfrequently  attends  this  excessive  debility. 
The  malady  has  now  obtained  that  stage  in  which  a  change 
must  take  place,  and  if  it  be  toward  recovery,  the  irequency 
of  the  pulse  becomes  diminished  ;  the  skin  becomes  relaxed  ; 
the  tongue  moist  and  cleaning ;  the  eruption  fades ;  stupor 
subsides,  and  consciousness  returns.  This  change  toward  con- 
valescence is  sometimes  distinguished,  like  synochus,  by  a 
copious  perspiration  or  urination,  and  the  patient  falls  asleep, 
to  awake,  comparatively,  a  new  or  different  being. 

But  should  the  change  be  for  the  worse,  then  the  patient 
lies  upon  his  back,  eyes  half  closed,  mouth  open,  delirium 
with  subsultus  tendinum,  hiccough,  picking  at  the  bed-clothes, 
difficult  deglutition,  involuntary  discharge  of  urine,  extremi- 
ties  cold,  features   collapsed,  pulse,   perhaps,  absent  at  the 


FEBRILE   F0KM3    OF   DISEASE.  91 

wrist.  The  physician  should  not  abandon  the  case  yet ;  if  he 
does,  he  may  possibly  learn  on  the  next  day,  to  his  shame,  that 
the  system  of  the  patient  rallied  through  the  night,  and  he  is 
convalescent.  When  there  is  no  neccessarily  fatal  lesion 
of  some  very  important  part,  it  may  be  said,  "  where  there  is 
life,  there  is  hope." 

Convalescence  from  this  form  of  disease,  as  might  be  ex- 
pected, is  slow,  but  it  generally  advances  to  good  health  with 
very  little  liability  to  relapses.  The  time  occupied  in  running 
its  course  is  very  variable ;  it  may,  in  mild  cases,  conclude 
in  recovery  in  a  week,  and  in  other  forms  of  a  more  violent 
nature  it  may  consume  four  weeks  ;  but,  generally,  one  week  is 
consumed  in  its  advancement,  one  to  its  completed  stage,  and 
one  to  its  decline.  We  should  add,  that  in  those  cases  in 
which  reaction  can  not  be  established,  death  may  supervene  in 
twenty-four  hours. 

Causes. — About  these  we  have  some  facts,  but  no  philosophy. 
The  most  common  resort  of  this  form  of  disease  is  in  camps, 
prisons,  ships,  hospitals,  and,  in  private  life,  the  filthy  abodes 
of  the  destitute  and  miserable.  It  is  inferred,  therefore,  that 
a  poisonous  effluvium  is  generated  from  the  bodies  and  excre- 
ments of  those  who  are  thus  confined  together.  Very  many 
facts  have  been  collected  to  render  it  very  probable  that  the 
poison  thus  generated,  may,  through  the  medium  of  the  at- 
mosphere, visit  the  disease  upon  those  who  have  not  had  any 
part  in  the  generation  of  the  poison.  It  is,  furthermore,  pret- 
ty generally  believed  that  the  poison  can  be  confined  in  cloth- 
ing, etc.,  and  thus  transported  beyond  the  region  of  its  genera- 
tion, and  re-produce  the  disease. 

It  is  also  believed  to  originate  in  epidemic  influences.  This, 
to  us,  is  a  puzzle,  that  the  human  body,  under  certain  circum- 
stances, and  the  atmosphere,  shall  produce  a  cause,  which,  in 
its  results,  shall  be  the  same.  Dr.  Wood  states,  that  he  has 
no  doubt  that  the  latal  epidemics  that  prevailed  in  our  coun- 
try between  1807  and  1820  were  of  typhous  fever.  Both 
sexes  and  all  ages  seem  to  bo  liable  to  it,  and  the  winter  season, 
rather  than  any  other,  the  time  for  its  most  frequent  appear- 
ance and  greatest  prevalence. 

Diagnosis. — This  form  of  fever  can,  in  a  great  measure, 
be  distinguished  from  all  others,  by  the  sordes  upon  the  teeth, 
gums,  lips  and  tongue ;  by  the  habitual  stupor  that  attends  it ; 
the  sufl'usion  or  injection  of  the  eyes ;  the  dusky  or  dark  hue 
of  the  countenance,  and  great  prostration  of  strength. 

The  typhoid  fever  is  most  frequently  confounded  with  it, 
but  from  it,  it  may  generally  be  distinguished  by  the  difier- 
ence  in  the  condition  of  the  bowels,  respectively.  In  ty- 
phoid, they  are  very  rarely  habitually  aperient;  while  in 
typhous    they    are     habitually   constipated.      Again,   alvine 


92  FEBEILE   F0KM8    OF   DISEASE. 

hemorrhage  is  common  to  the  former,  but  very  rare  in  the 
latter.  The  typhoid  eruption  differs  Irom  the  typhous ;  tym- 
panites is  common  to  the  former,  but  exceedingly  rare  in  the 
latter,  and  the  same  is  true  of  the  bronchial  rales,  which  gen- 
erally attend  the  former.  (See  the  article  on  Typhoid  and  Ty- 
phous Fever,  by  Dr.  "VV.  Jenner.) 

Prognosis. — This  should  always  be  regarded  as  uncertain ; 
but  the  appearance  of  diarrhea  or  fetid  perspiration,  in  the 
declension  of  the  disease,  and  a  change  of  the  petechise  from  a 
blackish  aspect  to  a  brighter  color,  may  be  regarded  as  favorable. 

Dr.  Eberle  says,  that  spontaneous  vomiting  during  the  first 
and  second  day  of  the  disease,  more  especially  when  the  un- 
pleasant cephalic  sensations  are  thereby  abated ;  slight  hemor- 
rhage from  the  nose,  about  the  sixth  or  seventh  clay  of  the  stage 
of  excitement,  is  a  good  indication,  and  so  is  a  moderate  diar- 
rhea at  an  early  period  of  the  disease. 

The  unfavorable  signs  are,  a  vast  number  of  livid  spots,  a 
sudden  disappearance  of  them,  black  aphthas,  no  thirst,  in- 
flamed fauces,  laborious  respiration  after  the  eruption  of  the 
petecchiee,  a  swelling  of  the  abdomen,  with  a  concomitant 
diarrhea,  highly  fetid  and  ichorous  stools,  coldness  of  the  ex- 
tremities, and  convulsions.  To  these  Dr.  Eberle  has  added  a 
still  more  certainly  fatal  class :  as  blindness,  involuntary  flow 
of  tears,  difficult  deglutition,  paralysis  of  the  tongue,  insensi- 
bility to  active  vesicatories,  and  involuntary  colliquative  stools 
and  hemorrhages.  After  all,  he  adds,  patients  do  sometimes 
recover  from  this  disease  after  many  of  the  most  alarming  of 
these  symptoms  have  made  their  appearance. 

Indications. — The  symptoms  of  this  form  of  fever  show 
that  that  chemico- vital  action  upon  which  the  calorific  func- 
tion depends,  is  greatly  arrested  and  deranged ;  that  the  vital 
laws  show  a  constant  tendency  to  yield  to  the  chemical ;  where- 
by the  entire  blood  mass  is  threatened  with  total  disorganiza- 
tion ;  consequently  the  whole  system  should  be  toned  up,  heat 
should  be  applied,  depuration  should  be  promoted,  and  the 
putrescent  tendency  of  the  system  should  be  counteracted. 

Treatment. — ^In  this  form  of  fever,  we  pursue  a  similar 
course  of  treatment  to  that  recommended  in  typhoid  fever,  with 
the  exception  that  counter-irritants  must  be  more  energetically 
applied  to  the  extremities  and  the  spinal  column,  together  with 
the  use  of  antiseptics,  when  putrid  symptoms  are  present,  as 
Vinegar,  diluted  Pyroligneous  Acid,  Elixir  Vitriol,  etc.  This 
condition  will  not  admit  of  sedatives  to  any  considerable  ex- 
tent, but  very  often  permanent  stimulents  in  combination  with 
tonics  have  to  be  adopted  from  the  beginning  and  continued 
throughout.  Notwithstanding  the  frequency  of  the  pulse,  seda- 
tives are  not  admissible,  for  this  depends  upon  the  nervous  de- 
bility and  not  upon  an  inflammatory  condition  or  high  vital 


FEBEILE    FORMS    OF   DISEASE.  93 

action.  K  this  condition  should  be  mistaken  and  sedative  or 
relaxing  agents  be  used,  the  patient  will  soon  sink  under  their 
employment. 

Genus  II. — Periodic  Fever. 

Introduction. — This  genus  embraces  those  febrile  forms 
which  are  usually  attributed  to  miasmata;  and  though  some 
of  them  are  not  strictly  periodical,  yet  their  remissions  are 
more  marked  than  those  we  have  treated  of  as  being  continued. 
The  opinion  is  pretty  generally  entertained  that  those  of  this 
genus  are  but  varieties — essentially  the  same — modified  by  the 
intensity  of  the  cause  and  the  constitutional  peculiarities  of 
the  assailed ;  nevertheless,  as  it  is  common  to  treat  of  them 
separately,  and  as  they  admit  of  well-defined  diflerences,  we 
shall  treat  of  them  as  so  many  species,  and  then  ample  room 
will  be  left  for  any  number  of  varieties. 

Species  I. — Intermittent  Fever — Fever  and  Ague.* 

The  symptoms  which  we  detailed  under  the  general  name  of 
fever,  as  applicable  to  the  forming  stage  of  fever,  apply  very 
accurately  to  the  same  stage  in  this.  We  will  add  one  symp- 
tom, and  so  far  as  the  writer  has  observed  the  phenomena  of 
this  stage  in  himself,  it  precedes  all  others,  and  frequently  by 
a  week  or  ten  days  ;  it  consists  of  a  sort  of  pungent  or  draw- 
ing pain,  as  though  the  epigastrium  was  being  drawn  to  the 
spine,  and  for  the  purpose  of  relief  he  frequently  took  full  in- 
spirations. After  he  came  to  observe  this  symptom,  in  con- 
nection with  this  form  of  fever,  he  never  failed  to  prevent  its 
occurrence  by  the  use  of  prophylactic  measures.  The  pain  is 
located  immediately  at  the  inferior  extremity  of  the  sternum. 
The  writer  has  not  found  this  symptom  recorded  by  any  one 
else,  nor  does  he  know  whether  it  obtains  generally  or  not ; 
but  if  it  does,  its  appearance  will  give  ample  time  for  prophy- 
lactic measures. 

We  have  before  remarked,  that  a  paroxysm  consists  of  three 
distinct  periods  in  this  form  of  fever :  the  cold,  the  hot,  and 
the  sweating. 

Cold  period. — ^This  begins  with  yawning,  listlessness,  and  a 
peculiar  sensation  in  the  back,  or  in  the  ends  of  the  fingers, 
which  are  not  easily  described.  The  patient  is  then  visited  by  a 
sense  of  horror  ;  a  tremor  of  the  muscles,  with  a  chattering  of 
the  teeth ;  a  sensation  of  extreme  cold,  which  commences  at 
the  extremities  and  travels  to  the  trunk  ;  it  appears  sometimes 
to  be  deeply  seated,  even  to  the  bones ;  a  pain  in  tlio  joints, 
back  and  head  ;  difficulty  of  breathing ;  pellucid  urine,  and  a 
quick,  small,  weak,  contracted  pulse,  which  can  scarcely  be 
numbered  on  account  of  the  tremor.     It  lasts  from  a  few  min- 


94  FEBRILE   FORMS    OF   DISEASE. 

utes  to  three  or  four  hours,  and  even  longer,  when  reaction  is 
not  effected  ;  death  frequently  happens  in  this  stage. 

During  the  action  of  this  period,  the  patient  betrays  a  con- 
stant disposition  to  yawn ;  the  skin  becomes  so  powerfully  con- 
tracted that  the  finger  rings  will  drop  from  the  hand ;  the  mind 
becomes  unsteady,  irritable,  taciturn,  and  morose  ;  the  muscu- 
lar tremor  is  sometimes  so  violent  as  to  resemble  a  paroxysm 
of  convulsions ;  these  rigors,  as  they  are  usually  called,  when 
long  continued,  leave  the  patient  greatly  exhausted.  A  dry 
cough,  deep  sighing,  and  a  feeling  of  stricture  across  the  chest 
ai'e  usually  present. 

Dr.  Ebeiie  says,  that  in  debilitated  persons  a  violent  fit  of 
rigors  often  induce  a  complete  state  of  stupor  or  coma ;  but  in 
the  south,  we  have  seen  these  symptoms  in  the  athletic.  In 
this  period,  the  thirst  is  urgent,  and  although  cold  water  is  de- 
sired, the  patient  fears  to  take  a  second  draught,  because  he 
found  the  first  to  increase  the  paroxysm.  The  chill  is  some- 
times,so  slight  as  to  escape  the  cognition  of  the  patient;  the 
finger  nails,  more  than  any  other  part,  expose  the  fact. 

As  this  period  becomes  merged  in  the  next,  a  sensible  and 
a  very  unpleasant  mixture  of  heat  and  cold  travels  over  the 
patient.  About  the  time  of  this  change,  nausea  and  vomiting 
supervene,  but  sometimes  earlier,  and  continue  until  the  hot 
stage  is  formed. 

Hot  period — Pyrexia. — As  the  last  stage  passes  off,  an  in- 
tolerable heat  succeeds.  The  arteries  are  dilated,  and  strike 
forcibly  against  the  finger ;  the  respiration  is  strong  and  free. 
The  head  aches  and  the  patient  frequently  becomes  delirious, 
or  we  should  have  said,  perhaps,  that  when  the  patient  is  of  a 
dense  fibrous  constitution,  he  is  very  apt  to  become  delirious. 
An  intense  thirst  is  complained  of,  and  a  frequent  demand  is 
made  for  cold  water ;  the  tongue  is  white  ;  the  urine  is  high 
colored  ;  much  heat  is  complained  of  about  the  ])raecordia,  and 
sometimes  there  is  a  swelling  of  the  epigastrium.  The  blood, 
when  drawn,  is  more  dense  than  usual,  red  on  the  surface  but 
dark  colored  within,  with  only  a  small  portion  of  serum,  and 
less  cohesive  than  in  health. 

When  this  stage  is  being  introduced,  a  warm  and  pleasant 
glow  is  felt  about  the  face  and  temples,  and  from  this  the  whole 
surface  becomes  hot ;  nevertheless,  at  this  early  stage  of  the 
period,  if  a  limb  be  moved,  sudden  sensations  of  cold  will  be 
felt  running,  as  it  were,  in  divided  rays  over  the  surface.  But 
presently  all  traces  of  the  former  period  have  passed  off;  the 
skin  becomes  distended  with  blood,  the  cheeks  are  flushed,  and 
the  eyes  become  brilliant.  Dr.  Wood  says  that  Fordyce  found 
the  temperature  of  the  system  to  be  105°  by  the  thermome- 
ter, and  Mackintosh,  he  says,  has  known  it  to  be  as  high  as 
110°  in  Great  Britain,  and  112°  in  warm  climates.     There  is 


FEiSBtLE   FOfiMS  OP   DISEASE;  95 

no  desire  for  food,  and  sometimes  nausea  and  vomiting  are 
present. 

As  to  duration,  this  stage  is  as  various  as  the  preceding 
one,  but  it  is  generally  more  lengthened,  extending  some- 
times to  eighteen  hours.  The  febrile  action  is  frequently 
greater  than  in  continued  or  remittent  fever.  The  cerebral 
suflering  in  this  period  differs  from  that  of  the  cold  stage  in 
this,  it  is  more  deeply  seated  and  generally  more  severe.  At 
the  commencement  of  this  period  in  children,  convulsions  not 
unfrequently  occur. 

Sweating  period. — The  patient,  at  length,  feeling  as  though 
he  was  scorched  to  a  crisp,  is  relieved  by  a  copious  sweat  all 
over  his  body.  All  the  symptoms  now  remit,  and  the  per- 
spiration, after  continuing  three  or  four  hours,  but  sometimes 
much  longer,  entirely  disappears.  The  urine  deposits  a  lateri- 
tious  sediment ;  the  patient  falls  to  sleep,  and  an  intermission 
succeeds. 

Apyrexia. — This  period  embraces  that  time  which  transpires 
between  the  close  of  the  sweating  stage  and  the  commencement 
of  the  forming  one  of  the  next  paroxysm.  During  this  period, 
the  patient,  though  without  fever,  is  not  usually  entirely  free 
from  some  sensations  of  ill-health.  He  feels  as  though  he  had 
been  sick  ;  he  moves  about  as  though  he  suffered  from  languor, 
and  possibly  he  has  some  obtuse  pain  in  the  back  and  loins ; 
his  appetite  is  fastidious,  and  his  complexion  is  more  or  less 
sallow.  But,  on  the  contrary,  it  frequently  happens  that  he 
feels  entirely  clear  of  disease  and  has  an  appetite  that  is  even 
less  fastidious  than  in  health. 

We  shall  now  make  an  extract  from  Dr.  Wood,  for  the  pur- 
pose of  showing  how  little  is  understood  of  the  nature  and 
modus  operandi  of  fever.  We  select  him,  not  because  he  is 
the  most  vulnerable,  but  because  he  is  probably  the  most  es- 
teemed authority  in  this  country.     He  says  : 

"  It  has  frequently  been  stated  by  writers  that  each  stage  of 
the  paroxysm,  subsequent  to  the  chill,  is  the  immediate  effect 
of  the  preceding  stage ;  in  other  words,  that  the  cold  stage 
produces  the  hot,  and  the  hot  the  sweating ;  but  this  is  scarce- 
ly probable,  at  least  with  regard  to  the  first  two  stages,  which 
bear  no  proportion  to  each  other — a  protracted  and  severe  chill 
being  frequently  followed  by  less  fever  than  a  very  slight  one, 
and  the  fever  sometimes  occurring  without  any  preceding  chill 
whatever.  The  probability  is,  that  while  the  depression  at- 
tendant upon  the  cold  stage  is  naturally  followed  by  some  de- 
gree of  febrile  reaction,  as  a  necessary  consequence,  the  mor- 
bific cause,  whatever  it  may  6^,  is  capable  of  producing  the 
hot  stage  by  a  direct  influence. " 

We  would  like  to  know  what  sort  of  action  this  "  direct 
influence"  is.     We  are  utterly  unable  to  conceive  how  any 


96  FEBEILE   FORMS    OF   DISEASE. 

one  can  pursue  a  sound  practice  in  fever,  whose  views  of 
its  pathology  are  so  beclouded — the  fact  is,  they  do  not,  and 
can  not. 

We  do  not  expect  to  explain  this  matter  to  the  satisfaction 
of  the  lovers  of  the  mysterious,  but  we  are  of  the  opinion  that 
it  can  be  done  for  those  who  seek  only  for  the  truth,  and  love 
it  the  more  for  its  simplicity.  Then,  first,  what  is  fever  ?  We 
have  answered  this  question  several  times,  but  it  will  do  no 
harm  to  do  so  again.  It  is  vital  action  accumulated  for  the 
removal  of  obstructions  from  the  system.  Now,  a  proper  ap- 
plication of  the  law  contained  in  this  answer,  will  enlighten 
the  whole  subject. 

When  the  vital  force  is  great,  and  the  obstruction  is  com- 
paratively trifling,  is  it  not  obvious  that  the  former  may  act 
upon  the  latter  without  the  patient  or  his  physician  having 
any  other  cognizance  of  the  fact  than  is  rendered  apparent  by 
the  sequence,  which  is  fever  ?  It  is  not  characteristic  of  a 
great  man  to  make  much  fuss  over  a  little  thing,  then  why 
should  we  expect  such  a  vital  force  to  make  a  great  fuss — to 
shake  the  patient  almost  to  pieces,  to  overcome  a  little  ob- 
struction ?  A  little  obstruction  may  occasion  a  more  last- 
ing fever  than  a  great  one,  because  the  concentration  of 
vital  force  will  be  less — its  energies  will  not  be  thoroughly 
aroused.) 

When  the  vital  force  is  compared  with  the  amount  of  the 
obstruction,  if  feeble,  the  chill  will  be  thorough  and  protract- 
ed, and  in  the  event  that  it  is  overcome,  it  lias  been  efiected  by 
a  thorough  concentration  of  the  force ;  and  whenever  success- 
ful, there  will  be  no  great  excess  to  become  manifested  in  the 
form  of  fever. 

In  the  former  case,  though  the  fever  may  be  considerably 
protracted,  the  patient  will  recover  without  foreign  aid ;  but, 
in  the  latter,  two  or  three  paroxysms  may  so  exhaust  the  vital 
force  that  death  may  result  in  the  next  struggle — simply  be- 
cause it  is  overpowered  by  the  obstruction.  In  the  latter  case, 
furthermore,  when  successful,  almost  as  soon  as  the  cold  stage 
has  passed,  the  sweating  or  secreting  stage  will  be  introduced, 
simply  because  the  force  did  not  and  could  not  rise  much  above 
the  secretory  condition  of  the  system. 

Upon  this  subject,  we  beg  leave  to  refer  Drs.  Wood,  Eberle, 
Cheyne,  Watson,  and  the  whole  Allopathic  school,  to  the 
"  Thesis  "  of  Freeman  Franklin,  M.  D.,  of  the  Electic  Medi- 
cal Institute,  of  Cincinnati,  which  will  be  found  in  the  April 
number  of  the  Eclectic  Medical  Journal  of  that  school  for 
1853.  We  say  unhesitatingly,  and  under  a  full  sense  of  our 
responsibility,  that  he  has  conveyed,  in  four  or  five  pages, 
more  sound  and  correct  views  of  the  pathology  of  fever, 
than  can  now  be  found  in  everv  Old-School  book  extant.     The 


FEBRILE   FOKMS    OF   DISEASE.  97 

youEg  gentleman  merits  this  compliment,  and  the  Old  School 
the  rebuke. 

As  a  difference  of  latitude,  of  topographical  condition,  of 
constitution,  and  of  modes  of  life,  produce  great  departures 
from  the  general  history  we  have  given  of  this  form  of  fever, 
it  becomes  proper  that  we  should  notice  a  few  of  them,  "^he 
principal  of  these  peculiarities  Dr.  Eberle  has  reduced  to  the 
following:  1,  the  inflammatory;  2,  the  congestive;  3,  the 
goMric  ;  4,  the  malignant ;  to  which  we  add :  5,  the  masked 
intermittenis. 

1.  Inflammatory  Intermittents.  —  According  to  the  same 
author,  Richter  is  of  the  opinion  that  this  form  of  intermit- 
tent fever  occurs  more  frequently  during  the  winter  and 
spring,  and  that  it  occurs  more  frequently  in  quotidians  than 
in  tertians,  and  in  the  latter  more  than  quartans.  Those 
who  constitute  our  first  class  are  the  most  Irequent  subjects 
of  it. 

It  is  usually  introduced  with  rigors,  and  in  the  hot  stage  the 
temperature  of  the  surface  rises  high  and  the  pulse  beats  with 
ftillness  and  strength.  But  the  diagnostic  symptom  of  this  form 
is  the  fact,  that  no  matter  how  thoroughly  marked  the  sweat- 
ing stage  may  have  been,  a  state  of  pyrexia  will  still  continue 
to  the  next  paroxysm.  Much  of  the  violence  of  the  hot  stage, 
to  be  sure,  has  subsided — the  pulse  has  lost  its  fulness,  but 
much  of  its  quickness  and  tenseness  remains  ;  ttie  thirst,  too, 
is  reduced,  but  still  the  patient  demands  drink,  and  still  com- 
plains of  some  pain  in  the  extremities  and  back.  The  discon- 
tented and  fretful  condition  of  the  patient  indicates  the  exist- 
ence of  much  irritability  in  the  system.  Richter,  says  Dr. 
Eberle,  teaches  that  this  variety  of  intermittents  is  but  seldom 
attended  with  gastric  disturbances. 

2.  Congestive  intermittents. — This  form  of  the  disease  does 
not  occur  often  in  this  climate,  n  jr  very  frequently  even  in  the 
south.  Those  who  become  tlie  subjects  of  it  are  of  the  third 
class,  and  who,  in  the  north,  would  probably  die  of  phthisis 
pulmonalis. 

For  tlie  reason  that  we  have  before  given,  the  cold  stage  is 
greatly  protracted,  and  all  the  symptoms  indicate  a  highly 
congested  condition  of  all  the  viscera,  such  as  pain  in  the  head, 
a  sense  of  weiglit  and  oppression  in  the  ehest,  fainting,  verti- 
go, a  feeble  pulse ;  beside  these  symptoms  of  the  cold  stage, 
the  hot  is  never  clearly  developed — it  does  not  present  a  single 
feature  of  this  period  as  it  usually  obtains.  It  develops  itself 
very  slowly — the  skin  scarcely  becomes  warm,  the  respiratory 
function  continues  oppressed,  the  countenance  continues  to  ap- 
pear anxious,  and  the  pulse,  though  frequent,  is  small  and 
tense — and  probably  the  only  heat  complained  of  appears  to 
be  internal,  and  but  seldom  demanding  drink. 


Jm  FEBRILE   FOEMS   OF   DISEASE. 

3.  Gastric  intermittents. — This  variety,  as  might  be  infer- 
red fi-om  its  name,  is  attended  by  much  gastro-enteritic  irrita- 
tion, from  the  redundancy  of  bile,  a  hyper-secretion  of  which 
is  going  on  in  the  liver ;  the  skin  wears  a  jaundiced  complex- 
ion ;  the  m-ine  is  charged  with  bilious  matter ;  nausea  and 
vomiting  of  bilious  matter  is  common  ;  the  tongue  appears  to 
the  taste  to  be  bitter ;  much  pain  is  complained  of  in  the  fore- 
head. As  the  sequelae  of  this  form  of  disease,  we  may  antici- 
pate much  visceral  derangement,  as  a  cachectic  condition  of 
the  system,  and  induration  of  the  liver  and  spleen. 

This  form  of  disease  usually  appears  in  the  fall,  and  has,  in 
the  opinion  of  the  writer,  no  necessary  connection  with  the,  so- 
called,  miasmata.  He  has  witnessed  it  only  in  those  who  had 
been  exposed  to  the  preceding  summer's  sun,  whereby  the 
cutaneous  system  became,  not  only  deranged,  but  greatly 
debilitated,  and  through  a  failure  of  its  function,  the  disease 
resulted. 

4.  Malignant  intermittent — Congestive  chill. — Dr.  Eberle 
says,  that,  according  to  Alibert,  this  form  is  of  frequent  occur- 
rence in  the  south,  and  is  always  of  a  dangerous  character.  It 
is  characterized,  he  says,  "by  a  copious  and  fetid  perspiration 
in  the  third  stage,  together  with  colliquative  hemorrhages 
from  various  parts  of  the  body,  sometimes  petecchiae  and  other 
marks  of  malignity.  They  run  their  course  with  great  rapidi- 
ty, death  usually  taking  place  in  the  third  paroxysm," 

The  writer  has  seen,  and  has  had  to  contend  with,  many 
cases  of  this  form  of  disease,  and  he  has  never  known  it  to  oc- 
cur except  in  the  first  class  of  persons — the  strong  and  more 
or  less  athletic.  The  first  and  second  paroxysms  are,  so  far  as 
he  has  observed,  uniformly  mild,  and  the  patient,  during  the 
intervals,  will  employ  himself  as  usual ;  but  the  third  parox- 
ysm is  characterized  by  the  above-narrated  symptoms.  Ali- 
bert says  that  death  takes  place  in  the  third  paroxysm ; — 
to  this  remark  we  will  add,  and  it  always  happens  in  the  cold 
stage. 

It  is  thought  to  be,  and  if  neglected  or  inefficiently  treated 
it  certainly  is,  a  dangerous  disease.  The  writer  thinks  it  hard- 
ly probable  that  one  per  cent,  of  unaided  patients  recover ; 
nor  has  he  ever  known  one  to  recover  in  the  Old  School  prac- 
tice— and  yet,  in  the  main,  its  practice  was  foun  led  upon  cor- 
rect indications,  but  it  wanted  energy.  He  is  decidedly  of  the 
opinion  that  there  is  no  form  of  disease  more  manageable  than 
this ;  and  this  opinion  he  founds  upon  his  own  uniform  suc- 
cess. And  why  should  it  not  be  ?  It  never  assails  the  feeble, 
nor  those  of  a  broken-down  constitution ;  but  those  who  are 
otherwise  sound,  and  so  strong  as  to  require  only  proper  and 
prompt  aid  to  effect  a  reaction. 

5.  Masked  intermittents, — Under  this  head,  it  is  useless  for 


FEBRILE   F0KM8    OF   DISEASE.  99 

US  to  do  more  than  to  apprise  the  young  physician  that  among 
those  forms  of  disease  which,  in  the  normal  mode  of  manifest- 
ing themselves,  are  familiar  to  every  practitioner,  do  frequent- 
ly obtnide  themselves  upon  our  notice  in  a  masked  form ;  and 
what  is  still  more  important  to  be  known,  is  the  fact  that  they 
will  yield  to  no  other  means  of  cure  than  those  which  are  ap- 
plicable to  the  regularly-formed  intermittent  fever.  In  other 
words,  it  appears  that  the  disease  or  obstruction  which  gener 
ally  results  in  Mdiat  is  known  as  intermittent,  does,  in  conse- 
quence of  local  or  some  general  variety  of  infirmity,  appear  in 
that  form  of  disease  in  which  the  said  infirmity  would  most 
likely  manifest  itself.  As  an  illustration  of  our  meaning,  we 
remark  a  tooth  is  so  decayed  as  to  expose  its  nerve,  which 
by  aching  indicates  the  usual  morbid  action  of  the  system,  la- 
boring under  the  usual  cause  of  intermittent  fever,  the  reactive 
power  expends  itself  in  the  form  of  odontalgia.  This,  we 
opine,  is  the  true  explanation  of  the  fact,  just  as  gastric  de- 
rangement is  manifested  in  the  same  manner,  and  for  the  other 
reason,  that  masked  intermittents  can  be  cured  only  as  pure 
intermittent  is. 

Of  the  masked  form  of  intermittent  fever.  Dr.  Brown  (En. 
Prac.  Med.)  has  given  a  catalogue,  from  which  the  following 
are  extracted — but  without  his  appended  authorities :  Pleuritis, 
carditis,  peritonitis,  ophthalmia,  swelling  of  the  head,  urtica- 
ria, scarlatina,  rheumatism,  gout,  epistaxis,  odontalgia,  ceph- 
alalgia, encephalitis,  meningitis,  gastroenteritis,  dysentery, 
asthma,  hysteria,  epilepsy,  convulsions,  blindness,  dumbness, 
sneezing,  eructation,  leucorrhea  ;  but  neuralgia,  in  some  form, 
is  the  most  frequent  that  appears  in  this  disguise. 

Prognosis. — Simple  or  uncomplicated  intermittent  fever  can 
not,  directly,  be  regarded  as  a  dangerous  form  of  disease,  but 
when  long  continued  it  is  apt  to  lay  the  foundation  of  a  prema- 
ture death.  The  feet  and  legs  become  edematous,  the  spleen 
enlarged,  the  digestive  function  greatly  impaired,  and  finally 
dropsy  terminates  the  case.  But  the  practice  of  irregular 
habits,  and  the  use  of  trashy  and  iuuutritious  food,  have  as 
much  to  do  in  these  results  as  the  disease — indeed,  we  have 
seen  but  few  who  possessed  a  good  constitution,  and  lived  obe- 
diently to  the  organic  laws,  who  ever  had  the  disease. 

When  the  disease  assails  those  who  possess  a  highly  en- 
cephalic constitution,  passive  congestion  of  the  brain,  or  apo- 
plexy, may  be  so  far  anticipated,  as  to  place  us  on  our  guard. 
Prof.  Eberle  says:  "In  general  much  less  danger  is  to  be  ap- 
prehended from  this  disease  in  the  young  and  vigorous,  than 
in  persons  of  feeble,  nervous,  and  depraved  habits  of  body." 
We  should  think  so,  as  we  have  never  seen  the  disease,  except 
in  the  malignant  form,  in  persons  of  that  character.  He  fur- 
ther states :  "  Delirium  seldom  occurs  in  intermittents,  and 


1^0  FEBBILE   FOBMS    OF    DISEASE. 

when  it  does  happen,  it  must  be  viewed  as  uu&vorable  ;  and 
even  more  so  than  mere  coma."  We  do  not  believe  one  word 
of  this.  Dense  and  fibrous  constitutions  very  rarely  have  feb- 
rile action  without  delirium ;  and  yet  they  have  the  least  dan- 
ger from  this  disease.  The  writer,  during  five  years,  had  more 
than  twenty  paroxysms,  and  delirium  attended  them  all ;  and 
yet  he  never  had  a  threatening  one.  We  have  seen  much  of 
the  disease,  and  would  greatly  prefer  to  see  delirium  than 
coma. 

Before  closing,  it  is  proper  to  remark,  that  tertians  are  more 
manageable  than  quotidians,  and  they  again  much  more  so 
than  quartans.  It  is  our  opinion  that  simple  intermittent  lever 
is  always  founded  on  debility — and  hence  remittents  are  con- 
verted into  intermittents  by  bleeding  and  purging. 

Causes. — In  treating  of  the  causes  of  fever  in  general,  that 
which  pertained  to  this  particular  form  was  so  far  discussed, 
as  to  leave  us  but  little  to  say  at  present.  Our  readers  have, 
no  doubt,  learned  by  this  time,  that  we  have  no  more  faith  in 
the  doctrine  of  kaino-miasmata  or  malaria,  than  a  man  of 
common  sense  might  be  supposed  to  have  in  the  so-called 
"  spirit  rappings."  It  is,  we  believe,  a  settled  principle  in 
philosophy,  that  like  causes  will  produce  like  results — hence 
like  results  should  be  referred  to  like  causes.  Bear  this  in 
mind,  while  we  attend  to  Prof.  Eberle.  He  says:  "I  have 
seen  one  instance,  in  a  delicate  child,  where  a  distinctly-formed 
ague  was  manifestly  produced  by  intestinal  irritation,  from 
too  tree  an  indulgence  in  irritating  articles  of  food.  An  inter- 
esting case  is  related  by  Mr.  Earl,  in  which  a  regular  inter- 
mittent was  produced  by  the  irritation  of  a  small  piece  of  dead 
bone  in  an  old  wound,  and  which  was  at  once  arrested  on  re- 
moving the  irritating  substance."  He  further  states,  "  Rich- 
ter  observes,  that  worms  and  other  causes  of  intestinal  irrita- 
tion have  been  known  to  produce  intermitting  fever." 

What  a  wonderful  similitude  there  must  be  between  irrita- 
ting articles  of  food,  worms,  and  a  small  piece  of  dead  bone, 
and  kaino-miasmata  ! 

Let  us  notice  him  a  little  further.  "  Intermittents  are  never 
more  prevalent  than  when  the  days  are  very  warm,  and  the 
evenings  and  mornings  are  cool  and  damp." 

We  are  disposed  to  think  that  such  mornings  and  evenings, 
acting  upon  a  skin  that  had  become  exhausted  from  previous 
long  exposure  to  a  hot  sun,  would  be  sufficient  to  produce  an 
adequate  obstruction  to  call  forth  an  action  of  the  system. 

Proximate  Cause. — Upon  this  subject,  we  have  had  nothing 
but  speculation,  and  hence  a  little  more  can  do  no  great  mis- 
chief— therefore,  we  claim  a  brief  indulgence. 

Periodicity  is  a  law  of  the  animal  economy,  and  therefore 
we  shall  attempt  no  explanation  of  it,  but  we  may  elucidate 


FEBRILE   FOKMS   OF   DISEASE,    ETC.  101 

it.  A  man  sleeps  to-day  at  a  given  hour,  and  therefore,  on 
the  morrow  he  will  desire  to  sleep  again,  unless  his  mind  shall 
have  been  pre-excited.  This  is  our  experience.  Application : 
A  man  has  a  febrile  paroxysm  to-day,  why,  therefore,  should 
not  his  system  require  one  at  the  same  hour  on  the  follow- 
ing day  T 

But  there  is  another  view  that  may  be  taken  of  this  subject. 
Obstruction  to  the  performance  of  some  essential  function  has 
been  produced  ;  vital  force  accumulates  and  acts  for,  its  remo- 
val ;  but  the  force  accumulated  in  the  viscera  and  large  vessels 
was  at  the  expense  of  the  surface  and  extremities,  and  conse- 
quently in  them,  the  calorific  function  is  greatly  weakened  for 
a  time,  or  suspended,  and  a  chill  is  the  result,  Next,  the  force 
acts,  and  the  action  is  called  fever,  and  in  this  action  it  is  ex- 
pended, and  depuration  is  the  result ;  but  the  obstruction  is  not 
all  removed,  and  therefore,  as  soon  as  preparation  can  be  efl;ect- 
ed  for  another  paroxysm,  it  returns ;  and  thus  a  habit  is  finally 
established  which,  sooner  or  later,  under  favorable  circum- 
stances, will  spontaneously  leave  the  system.  Connected  with 
the  subject  there  are  many  minor  phenomena,  for  which  we 
have  no  explanation. 

Indications. — As  intermittent  fever  results  from  obstruc- 
tions in  debilitated  constitutions,  the  indications  must  be  to 
assist  the  vital  force  to  remove  the  former  and  to  strengthen 
the  latter. 

Treatment  . — At  the  commencement  of  this  disease,  an 
emetic  must  be  administered,  if  possible,  just  previous  to  the 
return  of  the  cold  stage,  which  may  be  followed  by  a  purga- 
tive, if  the  patient's  strength  will  admit ;  and  in  very  severe 
attacks,  this  course  must  be  continued  daily  for  several  days  in 
succession.  After  the  action  of  the  first  emetic,  anti-periodics 
must  be  given,  and  continued  through  the  whole  course  of  the 
disease,  without  regard  to  any  of  its  particular  stages.  The 
anti-periodics  which  have  proved  most  etficious  in  our  hands, 
are  Quinia,  Prussiate  of  L'on,  Hydrastiu,  and  Cornin,  in  the 
following  combination : 

]^.         Sulphate  of  Quinia, 

Fero-cyanuret  of  Iron, 
Hydrastin, 

Gornin,  ad  xv  grs.  Mix. 
Divide  this  into  ten  powders,  of  which  one  may  be  given  every 
hour,  until  the  disease  is  aiTested.  K  much  influence  upon 
the  head  should  ensue,  the  dose  of  Quinine  may  be  lessened 
or  altogether  omitted.  K  catharsis  is  required  during  the 
treatment,  a  combination  of  Podophyllin  and  Leptandrin,  or 
the  Compound  Pill  of  Podophyllin,  will  be  preferable  to  aU 
other  cathartics,  as  they  act  both  by  treeing  the  bowels  and 
unloading  the  congested  Liver. 


FEBRILE    FOEMS    OF   DISEASE,    ETC. 

In  cases  where  there  is  much  gastric  irritability,  accompa- 
nied with  nausea  and  vomiting,  and  an  inabilit}-  to  retain  any- 
thing upon  the  stomach,  sinapisms  applied  to  the  epigasti-ic 
region,  hot  applications  to  the  feet,  with  Lnpulin  or  small  por- 
tions of  Opium  carefully  administered,  will,  if  persevered  in, 
overcome  the  difficulty  ;  when  the  curative  treatment  may  be 
pursued. 

The  Extract  of  Leptandra  Virginica  and  Salicaccse  have 
been  employed  by  one  of  the  authors  with  much  success  in 
this  disease  (Eclec.  Med.  Jour.,  1852,  vol.  iv,  p.  295).  We 
exti'act  his  remarks  upon  the  use  of  the  latter: 

"  Of  the  SalicaceoB. — We  make  no  pretensions  to  botany, 
and  therefore,  we  can  not  designate  the  two  varieties  of  the 
tree  of  which' we  shall  treat.  They  are,  beyond  doubt,  indige- 
nous. Our  acquaintance  with  them  was  contracted  in  Arkan- 
sas :  one  is  common  to  the  Arkansas  and  Mississippi  rivers, 
and  probably  to  many  other  streams  ;  it  grows  into  a  very  tall 
tree,  and,  in  some  instances,  obtains  a  diameter  of  two  feet. 
Its  twigs  or  small  branches  are  very  brittle  at  their  junction 
with  the  stalk,  of  a  darkish  yellow,  not  bright,  like  a  foreign 
variety,  which  is  common  about  Cincinnati.  The  tree  is 
straight,  and  grows  near  the  edge  of  the  river,  and  frequently 
forms  dense  groves  of  small  growth  on  the  sand  beaches. 

"  The  other  variety,  in  Arkansas,  grows  scrubby,  about  the 
size  of  a  peach  tree,  on  stony  branches,  where,  in  the  summer 
season,  there  is  scarcely  any  moisture. 

"  Knowing  that  some  varieties  of  the  willow  had  been  used 
as  an  anti-periodic,  we  were,  during  our  first  season  in  the 
State,  forced,  for  the  want  of  a  better,  to  use  the  extract  of  the 
bark  of  the  tall  willow  first  above  described.  The  result  was 
so  satisfactory  that  we  sought  no  other  agent  while  in  the  vi- 
cinage of  the  river. 

"During  our  third  summer  in  the  State,  we  attended  a  very 
large  political  gathering  of  the  people  of  the  valley  of  the  Ar- 
kansas river,  upon  which  occasion  we  were  called  upon  for  a 
political  speech  ;  but  as  the  opportunity  did  not  suit  our  poli- 
tics, we  gave  them  one  upon  the  cure  of  intermittent  fever, 
which  prevailed  very  extensively  among  them. 

"  We  instructed  them  to  fill  a  ten  gallon  kettle  with  the  twigs 
and  bark  of  the  Arkansas  willow,  and  boil  them  about  thirty 
minutes,  then  re-fill  the  kettle  with  fresh  material,  and  thus 
proceed  until  they  shall  have  a  kettle  full  of  a  strong  decoc- 
tion ;  then  strain  it  and  boil  it  down  to  a  syrup ;  and  then,  to 
avoid  burning  it,  evaporate  it  in  the  sun  to  a  proper  consist- 
ence to  make  into  from  four  to  eight-grain  pills. 

"  In  the  use  of  these  pills,  we  instructed  them  to  resort  to  no 
variety  of  preparatory  medication,  but  to  commence  six  or  sev- 
en hours  before  an  expected  paroxysm,  and  give  two  of  these 


FEBRILE   FORMS    OF   DISEASE,    ETC.  103 

pills  every  hour,  until'  the  chill  came,  or  its  time  for  appearing 
should  have  passed. 

"  In  the  following  winter,  we  again  visited  that  portion  of 
the  State,  when  a  Mr.  Barnets  informed  us  that  the  pills  he 
made  cured  seventy-four  or  five  cases ;  that  another  gentleman, 
a  few  miles  from  him,  had  cured  more  than  fifty;  and  that, in 
all,  he  supposed  one  hundred  and  sixty  cases,  in  his  acquaint- 
ance, had  been  cured  by  our  address. 

"  In  our  practice,  we  never  knew  the  chill  to  follow  these  in- 
structions, when  thoroughly  carried  out. 

"It  is  not  our  opinion  that  this  willow  has  much,  if  any,  of 
the  astringent  principle  ;  these  pills  had,  more  frequently  than 
otherwise,  an  aperient  efiect. 

"Being,  upon  another  occasion,  in  the  southern  and  moun- 
tainous portion  of  the  State,  we  were  called  to  an  obstinate  case 
of  intermittent  fever,  and  had  no  medicine  to  combat  it  with. 
The  Leptandrin  was  not  known  to  exist  about  there,  nor  did 
the  tall  willow,  but  the  scrubby  willow  abounded.  Supposing, 
as  others  have  stated,  that  all  the  willows  possessed  similar 
qualities,  we  had  an  extract  made  of  it,  and  administered  it  as 
above  taught.  It  produced  no  observable  tonic  or  anti-periodic 
virtue,  but  so  obstinately  locked  up  the  bowels  as  to  do  more 
mischief  than  could  have  been  compensated  by  a  desti'uction 
of  the  chill.  It  is  a  powerful  astringent,  and  appears  to  be  as 
destitute  of  tonic  power  as  the  other  is  of  astringent. 

"  There  is,  in  this  vicinity  (Cincinnati),  a  willow  precisely 
resembling  the  Arkansas,  except  in  size ;  that  their  virtues  are 
the  same,  we  can  not  answer.  Among  the  forest  timber,  there 
is  another  similitude  equally  striking :  the  buckeye  of  this 
country  is  a  tree,  in  that,  it  is  a  shrub  ;  in  all  other  respects  the 
resemblance  is  perfect,  even  to  the  effects  upon  the  cattle  which 
eat  it.-' 

The  Tincture  of  Gelseminum  is  extensively  used  in  this  dis- 
ease by  many  of  our  physicians,  and,  as  far  as  we  can  learn, 
with  much  success  ;  our  use  of  it,  however,  has  been  limited, 
yet,  as  far  as  tested,  we  are  much  pleased  with  its  efiect. 

Altliough  we  have  stated  that  an  emetic  will  be  advisa- 
ble at  the  commencement  of  an  attack  of  intermittent  fever, 
yet  it  will  rarely  be  required  after  the  first  week  of  its  exist- 
ence. 

Notwithstanding  the  immense  amount  of  matter  from  time 
to  time  presented  to  the  profession  for  the  treatment  of  this 
disease,  we  have  found  the  above  simple  plan  fully  suffi- 
cient to  meet  the  most  obstinate  and  severe  cases  generally 
met  with. 


jIOA  febrile  fokms  of  disease,  etc. 

Species  U. — Remittent  Fever — Bilious  Fever — Bilious  Ro- 

mitte?it  Fever. 

In  order  that  the  reader  may  not  be  mislead  by  names  when 
reading  other  works  on  fever,  we  deem  it  proper  to  state,  that 
this  form  has  received  many,  in  consideration  of  the  locations 
in  which  it  has  fatally  prevailed,  or  from  the  local  circumstances 
which  are  supposed  to  give  origin  to  it,  viz:  miasmatic  fever; 
marsh  fever ;  country  fever ;  river  fever ;  lake  fever ;  Bengal 
fever;  African  fever;  Walcheren  fever;  Mediterranean  fever; 
but  it  is,  by  the  American  readers,  most  generally  understood 
by  the  names  of  bilious  fever,  bilious  remittent  fever,  and  re- 
mittent fever ;  yet,  even  these  names  are  objectionable,  because 
all  of  them  are  sometimes  just  as  applicable  to  other  varieties 
of  febrile  action.  Nevertheless,  the  term  remittent  conveys 
more  nearly  the  idea  we  wish  to  convey  than  any  other  by 
which  it  has  been  designated,  inasmuch  as  it  really  holds 
somewhat  of  an  intermediate  position  between  the  continued 
and  intermittent  forms  of  the  disease ;  and  it  may  be  taken  to 
represent,  in  respect  to  violence  or  grade,  a  mean  degree  be- 
tween intermittent  and  yellow  fever. 

Prof.  Caldwell  used  to  maintain  that  the  principal  difference 
between  these  three  forms  of  disease  consisted,  mainly  or  alto- 
gether, in  the  violence  or  concentration  of  the  cause  ;  and  this 
opinion,  we  believe,  is  considerably  prevalent  in  the  profes- 
sion. To  those  who  have  not  studied  closely  the  difference  in 
human  constitutions,  this  doctrine  may  appear  almost  or  quite 
unexceptionable;  but  our  long  acquaintance  with  the  latter 
subject  causes  us  to  entertain  some  doubt,  more  especially  as 
it  affects  the  intermittent  and  remittent  forms.  We  are  much 
disposed  to  regard  these  forms  as  such  varieties  only  as  may 
result  from  differences  of  constitution. 

Under  the  head  of  remittent  fever,  wi'iters  embrace  two 
widely-differing  varieties:  the  sthenic  and  the  asthenic.  In 
the  former,  all  the  vital  functions  are  vigorously  performed ; 
while,  in  the  latter,  the  vital  system  was  either  organically 
feeble  or  had  become  so  by  previous  disease,  or  debilitating 
habits.  When  treating  of  intermittent  fever,  we  found  that 
the  malignant  variety  never  obtained  with  those  of  a  feeble 
constitution.  In  this  form,  then,  the  sthenic  and  asthenic  can 
only  be  reconciled  as  members  of  the  same  form,  upon  the 
principle  that  intermittent  and  remittent  forms  of  fever  are  one 
and  the  same,  modified  by  telluric,  atmospheric,  and  constitu- 
tional differences. 


FEBBILE   FOKMS    OF   DISEASE.  105 

So  far  as  our  observation  has  extended,  and  it  has  not  been 
very  limited,  intermittent  fever  is  produced  by  the  action  of  a 
humid  atmosphere  upon  feeble  constitutions — the  humidity 
preventing  a  proper  cutaneous  action  ;  and  remittent  fever  re- 
sults from  a  less  humid  and  a  highly-heated  state  of  the  at- 
mosphere acting  upon  highly-vital  constitutions ;  hence,  in 
new  countries,  as  we  have  seen,  remittent  fever  may  prevail  in 
the  towns,  and  intermittent  in  the  country  where  forest  and 
marsh  abound.  This  explains  also,  why  it  is  that  intermit- 
tent fever  prevails  in  the  south  at  the  river's  edge,  and  remit- 
tent on  the  top  of  the  blufi',  where  ponds  and  marshes  do  not 
exist. 

From  such  facts  as  we  have  here  introduced,  it  would  seem 
that  strong  vital  force  is  best  adapted  to  an  unexciting  atmos- 
phere, and  that  a  feeble  one  does  best  in  an  exciting  or  electric 
one.  We  may  further  add,  that  we  have  always  found  malig- 
nant intermittent  to  obtain  under  remittent  influences.* 

Dr.  Joseph  Brown  (Cy.  Prac.  Med.),  treating  of  this  sub- 
ject, says :  '•'Remittent  is  the  endemial  of  warm  climates,  es- 
pecially of  those  of  which  the  soil  is  marshy ;  but  it  U  to  be 
met  with  in  the  more  temperate  regions  of  the  earth,  and  is 
not  unfrequeutly  observed  in  our  own  country,  especially  in 
seasons  of  universal  heat,  and  in  those  parts  of  it  where  under 
ordinary  temperatures  agues  are  prevalent."  This  observa- 
tion, as  far  as  it  goes,  supports  directly  the  opinions  we  have 
advanced. 

Dr.  Wood  says :  "Remittent  fever  has  the  same  types  as  the 
intermittent.  The  most  frequent  is  the  quotidian,  with  a  par- 
oxysm occurring  at  about  the  same  time  every  day.  The  ter- 
tian, with  its  every-other-day  paroxysm,  is  not  uncommon. 
The  quartan  is  very  rare.  Kext,  perhaps,  to  the  quotidian,  is 
the  dotible  tertian,  having  a  daily  paroxysm,  but  that  of  one 


*The  writer  was  early  induced  to  observe  closely  the  relations  of  autum- 
nal forms  of  disease  to  their  causes,  because  he  rejected  the  doctrine  of 
malarious  poison  -when  a  student  of  medicine,  and  under  the  voice,  too, 
of  its  champion  advocates,  Professors  Caldwell,  Chapman,  and  Hossack. 
lie  will  not  assert  that  the  doctrine  of  malaria  is  false,  but  that  he  be- 
lieves it  to  be,  and  expresses  this  conviction  for  the  purpose  of  inducing 
his  readers  to  observe  and  investigate  the  matter  for  themselves.  He 
would  have  them,  as  he  has  endeavored  to  do,  to  take  nothing  for  granted 
{hat  has  not  been  demonstrated,  unless  it  be  self-evident.  This  course  is 
indispensable,  if  we  would  escape  imposition,  for  the  most  flagrant  errors 
liave  received  the  sanction  of  truth,  by  the  universal  consent  of  mankind. 
Illustration:  Mineral  coal  is  of  re</e^a6Ze  origin?         ^ 

7 


10(5  FEBRILE    FORMS    OF    DISEASE. 

day  differing  from  the  next,  and  the  alternate  paroxysms  re- 
sembling each  other  both  in  character  and  in  time  of  occur- 
rence." 

The  phenomena  of  the  forming  stage  in  this  form  of  fever 
are,  in  general,  such  as  we  have  before  detailed  under  the  head 
of  "Order  I ;"  but  sometimes  this  period  is  remarkably  brief, 
for  the  second  or  cold  stage,  as  indicated  by  slight  chills,  is 
frequently  the  first  manifestation  of  the  disease.  For  a  time 
more  or  less  definite,  these  chills  alternate  with  flashes  of  heat, 
until  finally  the  latter  acquires  an  entire  ascendancy — the  feb- 
rile action  is  fully  established,  and  with  a  highly  increased 
condition  of  many  of  the  usual  prodromal  symptoms  ;  such  as, 
pain  in  the  back,  head,  and  extremities.  The  pain  of  acute 
rheumatism  is  not  more  severe  than  that  of  the  extremities 
frequently  is.  The  tongue  is  covered  with  fur;  a  jaundiced 
complexion  spreads  over  the  eyes  ;  nausea,  which  is  sometimes 
attended  with  a  vomiting  of  bilious  matter ;  the  right  hypo- 
chondriac and  epigastric  regions  labor  under  a  sensation  of 
weight  or  tension  ;  the  urine  is  scanty  and  charged  with  bile ; 
the  skin  is  generally  dry  and  hot ;  the  respiration  is  oppressed  ; 
the  pulse  is  but  seldom  hard  or  tense,  but  generally  lull  and 
frequent,  although  not  to  such  an  extent  as  to  exceed  116  or 
120  beats  per^minute ;  the  appetite  is  not  gone,  but  there  is 
usually  a  loathing  of  food ;  thirst  is  not  a  constant  though  a 
fi'equent  symptom.  It  is  common  for  the  eyes  to  be  sufiused 
and  the  lace  flushed. 

These  symptoms,  from  having  continued  from  six  to  eight  or 
ten  hours,  relax,  and  the  stage  of  remission  commences. 
About  the  neck  and  face  some  moisture  appears,  which  may 
or  may  not  extend  itself  over  the  whole  surface — giving  so 
much  relief  that  the  patient  soon  becomes  lost  in  a  quiet  and 
refreshing  sleep.  All  of  the  febrile  symptoms  have  abated, 
but  a  state  of  apyrexia  does  not  supervene.  The  duration  of 
the  abatement  or  remission  is  very  indefinite — extending  from 
two  to  twenty  hours,  depending  upon  the  existing  quotidian  or 
tertian  type,  as  the  case  may  be,  when  another  febrile  par- 
oxysm supervenes,  commencing  in  many  instances  as  the  pre- 
vious one  did,  with  chilly  sensations,  and  subsiding  in  perspi- 
ration. This  alternation  of  exacerbation  and  remission  contin- 
ues, with  a  gradual  increase  of  the  former  and  diminution  of 
the  latter,  until  the  zenith  of  the  disease  is  attained.  But  it  is 
proper  to  remark,  that  the  remission,  instead  of  being  attend- 
ed with  perspiration,  will  frequently  give  no  other  evidence  of 
its  existence  than  some  abatement  of  the  symptoms. 

In  mild  cases,  the  tongue  is  disposed  to  be  moist  throughout 
the  disease ;  but,  with  the  usnal  violence  of  the  disease,  it  be- 
comes dry  and  frequently  brown,  or  even  blackish,  particularly 


FEBBILE   FORMS    OF   DISEASE.  107 

about  the  surface.  In  most  cases,  the  epigastrium  becomes 
particularly  tender  to  pressure ;  in  some  instances,  gastric  op- 
pression is  complained  of,  and  in  others,  a  sensation  of  burn- 
ing pain  which  is  very  distressing.  During  these  symptoms 
there  is  apt  to  be  much  gastric  irritability. 

One  of  the  distinguishing  symptoms  of  this  form  of  disease 
is  yellowishness  of  the  skin  and  of  the  white  of  the  eyes,  and 
though  not  always  present  in  the  beginning  of  the  malady,  it 
rarely  refuses  to  make  its  appearance  by  the  fifth  day ;  its  tint 
of  color  sometimes  becomes  very  intense,  even  simulating  that 
of  yellow  fever,  and  not  unfrequeutly  quite  uniform  over  the 
system ;  it  has  even  been  known,  in  some  instances,  to  be  so 
secreted  upon  the  surface  as  to  stain  white  articles  coming  in 
contact  with  it.  If  bilious  diarrhea  supervenes,  this  peculiar 
secretion  of  the  skin  will  not  be  produced. 

At  the  beginning  of  the  disease,  nausea  and  possibly  vomit- 
ing may  be  among  the  symptoms ;  they  are  rarely  absent, 
however,  when  at  its  height.  The  ejections  are,  generally,  in 
the  latter  case  of  a  yellowish,  greenish,  grass-green,  bluish,  or 
brownish  color,  and  of  a  bitter  taste.  The  force  of  the  symp- 
toms are  not  unfrequeutly  reduced  by  nausea. 

The  bowels  are  not  always  constipated,  but  that  they  are, 
may  be  assumed  as  a  general  fact ;  and  the  fecal  excretions, 
though  sometimes  anti-bilious,  are  generally  the  contrary,  and 
probably  mixed  with  some  shade  of  green  or  black.  In  the 
advanced  stage,  a  bilious  diarrhea  sometimes  supervenes,  and 
occasionally  it  is  present  at  the  beginning,  and  when  nausea 
happens  to  be  present,  also,  the  introduction  of  the  disease  has 
somewhat  the  appearance  of  a  cholera  morbus.  As  most  gen- 
erally ob  ains  in  fever,  the  urine  is  small  in  quantity,  high  col- 
ored and  turbid,  and  in  an  advanced  condition  of  the  disease,  it 
is  usually  of  a  brownish  color.  As  might  be  expected,  there  is 
some  increase  of  it  during  the  remissions. 

There  is,  perhaps,  no  symptom  that  is  more  uniformly  pre^ 
sent  than  headache,  and  along  with  it  there  is  generally  one  or 
more  of  the  following  symptoms  :  ^vertigo,  intolerance  of  light 
or  sound,  roaring  or  singing  in  the  ears,  redness  of  the  con- 
junctiva, flushing  of  the  face,  delirium,  drowsiness,  tetanic 
spasms,  paralytic  symptoms,  wakefulness,  hiccough,  etc. 

Finally,  the  reader  is  not  expected  to  meet,  in  observations 
upon  this  form  of  disease,  witii  all  the  symptoms  we  have  enu- 
merated in  any  case ;  and  he  should  remember,  furthermore, 
that  there  is  perhaps  no  other  form  of  fever  that  presents  so 
many  modifications  of  type,  grade,  and  variety.  We  have 
therefore,  only  attempted  to  represent  that  character  which 
may  be  drawn  by  generalizing  a  majority  of  its  visitations. 

l)r,  Joseph  Brown  says :  "•Recovery  may  be  expected  if  the 
Dulse  becomes  more  full  and  expansive,  the  heat  more  equal- 


108  FEBRILE   FOKMS   OP  DISEASE. 

ized  over  the  surface,  the  pain  of  the  head  and  epigastrium  less 
distressing,  and  if  the  countenance,  though  still  flushed,  loses 
the  purple  hue  which  it  previously  possessed.  A  favorable  in- 
ference may  be  drawn,  too,  Irom  the  remissions  oecoming  more 
distinct,  the  conjunctivse  being  less  vascular,  the  bowels  more 
obedient  to  the  action  of  purgatives,  the  restoration  of  a  more 
abundant  urinary  secretion,  and  the  appearance  of  bile  in  the 
matters  vomited.  The  mean  duration  of  the  disease,  in  cases 
of  recovery  is  about  fourteen  days." 

Dr.  Wood  makes  the  average  duration  to  be  about  the  same 
period,  but  very  properly  adds,  that  it  sometimes  terminates  as 
early  as  the  fifth  or  seventh^  and  often  about  the  ninth  or  ele- 
venth ;  but  sometimes  it  is  protracted  to  twenty-eight  days. 

The  writer  never  had  a  case  to  extend  beyond  nine  days,  and 
frequently  they  terminated  on  the  seventh  ;  yet,  in  the  practice 
of  his  neighbors,  he  has  known  cases  to  continue  twenty-seven 
days  and  never  less  than  twenty.  He  alludes  to  those  cases 
only  to  which  be  was  called  in  consultation  that  had  passed 
into  the  typhoid  character — M'hich  never  happened  in  his  prac- 
tice. He  does  not  believe  that  the  disease  has  a  prescribed 
<;ourse  to  run.  An  energetic  and  proper  practice  will  never 
uuifer  a  case  to  run  fourteen  days. 

Remittent  fever  is  considerably  modified  by  the  season  of 
the  year  in  which  it  may  appear.  When  it  appears  in  the 
spring,  it  is  apt  to  produce  thoracic  symptoms  of  a  dangerous 
character ;  when  in  the  summer,  the  brain  and  the  nervous 
system  become  the  most  vulnerable,  and  in  the  autumn,  the 
abdominal  viscera  will  suffer  the  most. 

Dr.  J.  Brown  treats  of  one  symptom  which,  it  seems,  has 
been  noticed  only  by  Dr.  R.  Jackson  and  himself;  it  is  what 
we  would  denominate  a  suicidal  monomania,  instead  of  gen- 
eral delirium.  It  seems  to  have  puzzled  him  very  much,  more 
particularly  as  jpost  inortetn  examinations  revealed  nothing  I 
If,  in  such  cases,  he  had  examineu  the  parietal  ridge,  imme- 
diately behind  the  coronal  suture,  he  would  have  found  that 
part  largely  developed.  Monomania  of  any  kind,  in  all  feb- 
rile cases,  depends  upon  special  mental  powers  in  a  high  state 
of  endowment  or  excitement.  He  speaks  also  of  some  who, 
while  in  the  fever,  predicted  that  they  would  die — and  die 
they  always  did,  but  the  secret  cause  and  liilfillment  of  the 
prediction  be  could  not  divine.  If  be  had  phreuologically  ex- 
amined them,  he  would  have  found  a  large  endowment  of  cau- 
tion, and  a  small  one  of  hope.  Even  in  cases  of  general  de- 
lirium, it  is  not  uncommon  lor  some  particular  idea  to  predomi- 
nate. As  to  the  circumstance  of  their  dying,  there  is  nothing 
strange  ;  but  it  would  be  strange  for  men  to  recover  from  un- 
der a*  constantly  abiding  impression  of  fear,  so  common  aod 


FEBRILE   FOEMS   OF   DISEASE.  109 

natural  to  such  an  organization,  more  especially  when  submit- 
ted to,  as  an  inevitable  doom. 

In  the  course  of  this  fever,  those  of  its  subjects  who  possess 
a  part  so  feeble  that  it  can  not  resist  invasion,  inflammation  is 
apt  to  be  induced,  and  upon  this  circumstance,  rather  than  upon 
the  inherent  cliai-acter  of  the  fever,  does  its  fatality  depend. 
The  most  vulnerable  parts  are  usually  the  stomach,  the  spleen, 
the  lungs  and  the  brain.  When  inflammatiun  supervenes,  the 
treatment  will  be  found  under  the  head  of  inflammation  of 
these  organs,  respectively. 

It  sometimes  liappens  that  this  fever  presents  «nly  a  typhous 
character  from  the  beginning.  This  may  depend  upon  an  in- 
herently feeble  constitution,  but  we  are  of  the  opinion  that  it 
originates  more  frequently  in  those  who  have  become  enfee- 
bled by  previous  disease  or  vicious  habits.  Bilious  fever  of 
the  ordinary  character  frequently  degenerates  into  the  typhous 
through  neglect,  but  more  frequently  through  mal-practice — 
the  very  common  anti-phlogistic.  When  the  disease  is  of  this 
character,  the  treatment  will  be  found  under  the  head  of  ty- 
phous fever. 

It  frequently  happens  that  individual  parts  share  a  greater 
portion  of  the  diseased  action  than  others,  and  that,  too,  with- 
out the  existence  of  inflammation ;  but  it  is  pro]^er  to  add, 
that  such  local  manifestations  of  disease  should  render  us  vigi- 
lant lest  inflammation  should  supervene.  Upon  these  local  de- 
terminations, varieties  of  this  fever  have  been  established ; 
hence  we  have  gastric-bilious  fever,  hepatic-l^ilious  fever,  and 
upon  the  same  principle  we  have  as  many  as  there  are  impor- 
tant parts  in  the  system ;  nevertheless,  these  local  modifica- 
tions should  alw-ays  command  our  earliest  attention. 

Convalescence. — We  have  but  rai*ely  witnessed  a  case  of 
convalescence  which  was  not  more  retarded  by  the  mal-prac- 
tice that  had  been  instituted,  than  by  any  pre-existing  pecu- 
liarity of  the  fever  or  of  the  constitution,  and  the  principal 
difficulty  we  always  found  to  be  referable  to  mercury  or  the 
lancet.  We  have  known  the  latter  to  be  used  to  reduce  the 
fever  to  an  intermitting  form — one  that  essentially  depends 
upon  debility.  Such  practitioners  must  act  upon  the  principle 
that  it  is  more  easy  to  remove  the  system  from  the  disease, 
than  it  is  to  remove  the  disease  from  it.  In  consequence  of 
the  use  of  the  lancet  and  of  mercury,  the  convalescence  is  not 
only  greatly  protracted,  but  attended  with  much  suffering. 

When  the  case  is  of  a  mild  grade,  the  convalescence  is  rapid 
and  altogether  favorable,  and  such  is  the  case  in  almost  all  of 
its  modifications  when  the  treatment  has  been  judicious.  The 
troubles  that  are  usually  classed  under  this  head  consist  fre- 
quently of  the  maniiestations  of  that  disease  which  Wiis- insti- 
tuted to  remove  the  pre-existing  one.     La  originally  frail  eon- 


110  FEBBILE   F0BM8    OF  DISEASE. 

stitutions,  this  stage  may  be  attended  more  or  less  with  co- 
pious uight-sweats,  imperfect  digestion,  constipation,  enlarged 
spleen,  and  perverted  action  of  the  liver. 

Causes. — Upon  this  subject  vsre  have  perhaps  said  enough, 
unless  we  had  something  more  certainly  true  than  has  yet  been 
divulged.  The  profession  generally  attribute  it  to  mia  ma, 
but  many  think  it  may  be  produced  by  heat  and  moisture.  In 
answer  to  this  hypothesis,  I)r.  Wood  inquires  why  it  does  not 
occur  among  sailors  at  sea,  and  in  our  cities.  We  answer : 
At  sea,  the  temperature  is  never  so  afHicting,  and  in  our  cities, 
in  consequence  of  its  hard,  paved,  and  shaded  condition,  there 
is  comparatively  but  little  moisture.  But,  in  this  matter,  all 
have  overlooked  an  important  feature — the  electricity  evolved 
by  evaporation.  One  square  foot  of  blact,  moist,  and  heated 
soil  will  throw  off  more  vapor  and  evolve  more  electricity  than 
a  square  rod  at  sea  or  in  the  city.  Here,  we  are  satisfied,  lies 
concealed  the  secret.  Under  the  head  of  intermittent  fever, 
we  delivered  our  opinion  as  to  the  cause  of  that  and  also  of 
this  form  of  fever. 

Diagnosis. — When  we  shall  have  treated  oi'  the  two  follow- 
ing species,  the  reader  will  have  but  little  use  for  a  special 
treatise  on  the  distinguishing  differences  between  this  and  other 
forms ;  and  yet,  there  is,  perhaps,  no  single  symptom,  taken 
separately,  that  may  not  occur  in  other  torms  of  fever.  To> 
judge  of  it  at  all,  we  must  view  it  as  a  whole.  The  most  marked 
symptoms  of  this  form  are:  l&t,  its  paroxysmal  character; 
but  this  is  even  more  perfectly  possessed  by  the  intermittent. 
2d.  Gastric  irritability  •,,  this  symptom  attends  this  form  more 
habitually  than  it  usually  does  others,  but  others  sometimes, 
equally  manifest  it.  3d.  Con&tant  pain  in  the  head ;  this  is. 
like  the  preceding.  4:th.  Bilious  phenomena ;  although  these 
ai'e  more  generally  present,  yet  the  same  is  true  occasionally  in 
othor  forms ;  hence  all  effort  to  divide  febrile  foanus  of  disease 
into  well  defined  species,  must  fail.  Fever,  therefore,  is  essen- 
tially the  same  in  all  ot'  its  modifications. 

Prognosis. — Under  this  head,  we  have  the  same  difficulties- 
to  contend  with.  In  taking  a  general  view  of  bilious  fever,, 
we  are  prepared  to  declare  it  to  be  favorable.  Under  a  prompt 
and  judicious  treatnient,  we  consider  it  (all  circumstances  con- 
sidered) a  less  fatal  and  a  more  manageable  form  than  the  in- 
termittent, simply  for  the  reason,  that  in  it  there  is  more  vital 
force,  generally,  to  contend  with  the  disease.  It  should  never 
be  considered  as  dangerous,  except  when  it  invades  a  diseased 
or  broken  dawn  constitution. 

Indicatiojss. — In  this  form  of  fever,  these  are  very  simple, 
but  require  an  energy  which  shall  be  in  harmony  with  the 
vital  force ;,  they  consisi  in  equalizing  the  circulation  and  the; 


FEBRILE   FORMS    OF   DISEASE.  Ill 

nervous  irritability  of  the  system,  to  remove  obstructions  and 
all  sources  of  irritation,  and  to  promote  depuration. 

Treatment. — At  the  commencement  of  the  febrile  stage  of 
this  form  of  fever,  or  during  the  first  day  or  two  of  its  attack, 
one  of  the  best  agents  that  can  be  given  is  an  emetic,  which 
not  only  removes  the  morbid  matters  accumulated  in  the  sto- 
mach, but,  by  giving  a  shock  to  the  nervous  system  generally, 
causes  more  or  less  profuse  diaphoresis,  mitigating  the  subse- 
quent severity  of  the  disease,  and  not  unfrequently  breaking  it 
up  at  once. 

The  emetic  operation  should  be  followed  by  a  cathartic,  for 
the  purpose  of  removing  congestion  of  the  portal  circle,  aug- 
menting the  secretory  action  of  the  liver,  and  unloading  the 
bowels  of  fecal  and  bilious  accumulations.  To  effect  this,  we 
know  of  no  better  agents  than  a  combination  of  Podophyllin, 
Leptandrin  and  Jalapin,  which  may  be  given  in  doses  and  at 
intervals  suited  to  the  urgency  of  the  case. 

After  the  action  of  the  cathartic  had  ceased,  should  there 
still  remain  pain  in  various  parts  of  the  system,  nausea,  or 
vomiting,  or  rapid  pulse  and  high  fever,  active  diaphoresis 
must  be  produced  and  maintained  for  a  few  hours.  To  effect 
this,  the  spirit  vapor-bath  is  the  best  method ;  and  may  be 
given  while  the  patient  is  in  bed  ;  or^the  Compound  Tincture 
of  Virginia  Snakeroot  may  be  administered  in  suitable  doses, 
and  repeated  at  short  intervals,  until  the  patient  perspires  Ireely. 
The  Gelsemin  or  the  Tinct.  of  Gelseminum  may  also  be  used. 

If  these  symptoms,  however,  should  not  be  present,  or  only 
slightly  exist,  the  practitioner  may  commence  at  once  with 
anti-periodics,  and  continue  them  through  the  whole  course  of 
the  disease.  The  agents  of  this  class  and  combinations  which 
we  prefer,  have  already  been  given  under  the  treatment  of  the 
preceding  forms  of  fever. 

For  the  determination  to  the  head,  which  is  almost  always 
present  in  this  disease,  the  same  course  must  be  pursued  as  al- 
ready named  in  the  treatment  of  continued  fever. 

Hiccough  may  be  relieved  by  Aqua  Ammonia,  Compound 
Spirits  of  Lavender,  Musk,  or  other  anti-spasmodics.  Rest- 
lessness, wakefulness,  and  similar  symptoms  may  be  relieved 
by  Compound  Powder  of  Ipecac,  and  Opium,  Sulphuric  Ether, 
or  infusions  of  Valerian,  Scullcap,  or  Black  Cohosh. 

Convulsions,  which  usually  take  place  with  children,  maybe 
treated  by  the  warm  bath,  sinapisms  to  the  extremities,  and 
the  internal  exhibition  of  a  dose  or  two  of  the  Tincture  of  Lo- 
belia and  Capsicum. 

The  patient  may  drink  freely  of  cold  water,  and  the  diet 
should  be  light  and  fluid,  with  proper  ventilation  of  the  room 
and  changing  of  linen.  If  acidulous  draughts  are  craved,  such 
as  lemonade,  tamarind  water,  or  currant  jelly,  apple-sauce,  and 


112  FEBKILE    FOKMS    OF   DISEASE. 

similar  digestible  preparations  of  acid  fruits,  they  should  be 
permitted.  During  convalescence,  the  diet  must  be  more  nour- 
ishing, but  strictly  of  a  digestible  character. 

Species  III. — Congestive   Fever — Pernicious  Fever — Perni- 
cious Remittent — Pernicious  Inter mnittent. 

Dr.  Wood  thinks  the  name  "pernicious  fever"  to  be  less 
exceptionable  than  any  other  that  has  been  selected  to  rep- 
resent this  form  of  fever.  This,  in  the  abstract,  may  be 
true,  but  the  one  we  have  adopted  has  become  so  familiar  from 
long  use,  particularly  to  our  western  and  south-western  peo- 
ple, to  whom  this  work  will  be  measurably  confined,  that  we 
prefer  it. 

If  congestive  fever  was  not  so  signally  distinguished  in  the 
popular  mind  from  all  others,  we  should  have  treated  of  it  as 
a  mere  variety  of  the  preceding,  which,  in  truth,  is  the  fact. 
Indeed,  we  may  say  that  all  the  forms  comprised  in  this 
genus  are  but  varieties — modifications,  and  they  should  be  so 
considered. 

Dr.  Wood  says,  that  he  does  not  apply  the  epithet  pernicious 
to  all  fatal  or  dangerous  cases  of  either  intermittent  or  remit- 
tent fever,  but  to  those  >'  in  which  there  is  great  and  sudden 
prostration  or  depravation  of  the  nervous  power,  or  to  use  a 
customary  phrase,  in  which  the  innervation  is  extremely  and 
most  dangerously  defective  or  deranged." 

This  manner  of  defining  his  meaning  amounts  to  about 
nothing,  because  it  applies  with  as  much  justice  to  those  forms 
of  iever  which  are  malignant  or  pernicious  in  consequence  of 
a  depraved  constitution.  In  such  cases,  there  is  prostration — 
a  want  of  innervation.  Our  idea  of  what  he  intended  to  define 
is  about  this :  A  pernicious  fever  is  one  in  which  the  obstruc- 
tion exceeds  the  resisting  power  of  the  vital  Ibrce — one  which 
will  readily  recover  when  the  force  is  so  aided  as  to  overcome 
or  remove  the  obstructions.  By  this  state  of  the  system  is 
commonly  understood  a  congestion  from  the  magnitude  of  the 
invasion,  and  not  Irom  any  previous  depravity  ot  the  constitu- 
tion ;  and  one  that  is  entirely  independent  of  any  local  inflam- 
mation. 

The  importance  of  this  distinction  is  very  considerable,  be- 
cause, in  the  first,  though  the  present  congestion  may  be  re- 
lieved, the  patient  will  probably  die  by  reason  of  constitutional 
depravity ;  i»ut,  in  the  second,  if  it  be  overcome — if  reaction 
be  established,  the  patient  is  saved — dissolution  and  recovery 
depend,  respectively,  upon  the  turning  of  a  single  point  and 
this  point,  to  a  malignant  extent,  rarely  recurs. 

Between  this  form  and  the  one  of  malignant  fever,  there  is 
one  striking  similitude,  it  never  occurs  in  a  depraved  or  feeble 


FEBRILE   FORMS    OF   DISEASE.  113 

constitution — but  in  the  strong ;  and  there  is  also  an  equally 
striking  difference ;  the  congestive  chill  is  confined  to  the 
usually  miasmatic  season  of  the  year ;  but  this  has  been 
known  to  commence  in  the  spring  and  to  prevail  through  the 
winter,  though  it  generally  obtains  in  the  same  season  with 
the  preceding. 

It  is  found  to  be  difficult  to  state  what  the  type  of  this  fever 
will  be,  until  after  two  or  three  days — the  period  of  doubt  and 
uncertainty  to  both  the  patient  and  physician — that  of  conges- 
tion, or  struggle  or  effort  to  overcome  the  obstruction.  If  this 
period  be  survived  the  type  may  be  intermittent,  remittent,  or 
continued.  But  if  the  congestive  period  be  procrastinated  lor 
two  or  three  days,  it  may  for  this  time  appear  as  an  intermit- 
tent or  a  remittent ;  and,  subsequently,  instead  of  either  of 
these  types,  it  may  appear,  as  before  stated,  in  the  continued 
form. 

Observations  from  various  parts  of  the  country  seem  to 
have  determined,  beyond  doubt,  that  there  are  two  leading 
modifications  or  varieties  of  this  malady ;  in  one  the  cerebro- 
spinal or  animal  system  seems  to  be  almost  exclusively  in- 
vaded ;  and  in  the  other,  the  ganglionic.  Whatever  may  be  the 
character  of  the  disease  as  subsequently  developed,  it  usually 
begins,  as  do  the  miasmatic  i'evers  in  general,  and  betrays  no 
pernicious  phenomena  until  the  arrival  of  the  second  or  third 
paroxysm ;  or,  as  before  intimated,  at  the  close  of  the  prod- 
romal stage  a  highly-congested  condition  of  the  system  may 
become  manifest. 

If  the  fever  is  to  be  of  that  modification  which  more  espe- 
cially invades  the  cerebro- spinal  system,  the  first  indication 
will  probably  be  drowsiness,  which  will  be  fo  lowed  by  more  or 
less  of  stupor.  The  patient's  attention  becomes  greatly  im- 
paired and  his  memory  unfaithful.  When  asked  a  question, 
he  may  be  so  far  aroused  by  it  as  to  attempt  an  answer,  but  will 
probably  stop  before  he  has  concluded,  and  possibly  in  the  mid- 
dle of  a  word. 

This  cerebral  condition  may,  and  not  unfrequently  does,  pass 
into  a  complete  coma,  and  from  an  impossibility  to  arouse  him, 
he  will  die  in  it.  The  circulation  appears  labored,  and  though 
the  pulse  indicates  fullness,  the  rapidity  is  frequently  even  less 
than  the  normal  standard ;  the  respiration  is  stertorous.  It  is 
said  that  epileptic  convulsions  do  sometimes  attend  this  fever, 
and  also  tetanic  spasms  and  difficult  deglutition. 

These  symptoms  sometimes  occur  in  the  fiffet  paroxysm,  but 
more  frequently  they  are  procrastinated  to  the  second,  or  even 
the  third.  This  form  is  consistent  Irom  the  start,  for  though 
the  first  paroxysm  may  be  light,  yet  comatose  symptoms  will 
prevail  more  or  less.  If  the  patient  shall  rally  trom  the  first 
severe  paroxysm,  which  is  generally  the  second,  the  following 


114  FEBRILE   FOBMS   OF   DISEASE. 

intermission  will  be  attended  bj  its  usual  symptoms ;  indeed, 
he  may  be  exempt  from  all  eymptoms  of  disease,  and  thus  go 
on  to  recovery  ;  but  it  is  unsafe  to  indulge,  without  the  greatest 
precautionary  means,  such  a  hope,  for  most  frequently  he  will 
continue  drowsy  and  stupid  until  the  next  paroxysm,  which 
usually  proves  fatal. 

The'  Medical  and  Surgical  Journal  of  New  Orleans,  vol.  iii, 
p.  733,  contains  an  article  from  Dr.  Bowling,  of  Montgomery, 
Ala.,  upon  the  subject  of  this  fever,  as  he  observed  it.  He 
states  that  the  approach  of  the  paroxysm,  after  a  few  febrile 
exacerbations,  was  attended  by  spasms  which  closely  resem- 
bled an  attack  of  tetanus,  that,  with  exacerbations  and  remis- 
sions of  fever,  continued  with  a  corresponding  degree  of  vio- 
lence. He  further  states,  that  after  the  occurrence  of  the 
spasm,  the  patient  in  no  instance  lived  longer  than  five  days, 
and  most  frequently,  if  not  arrested,  death  supervened  at  an 
earlier  period.  But  the  disease,  as  he  saw  it,  differed  from  its 
usual  character  in  this  :  it  was  attended  with  some  intellectual 
capacity. 

When  it  invades  the  ganglionic  system,  the  sight  of  one  pa- 
tient, in  the  forming  stage,  will  so  impress  his  general  pathog- 
nomy  upon  the  memory  of  the  physician  that  he  will  never 
forget  it.  Language  can  convey  no  adequate  idea  of  it.  His 
expression  is  one  of  alarm,  of  horror,  and  impending  dissolution ; 
his  features  are  shrunk,  shriveled,  and  apparently  reduced 
within  two  thirds  of  their  former  compass  ;  his  eyes  are  sunken 
in  their  sockets,  and  the  skin  is  of  a  bloodless  paleness.  The 
extremities  and  the  whole  surface  are  cold,  but  the  patient  does 
not  appear  to  be  conscious  of  it,  and  a  clammy  perspiration  cov- 
ers the  surface.  (Sometimes,  as  an  exception  to  this  general 
coldness,  the  chest  and  the  abdomen  are  much  heated.  The 
tongue  is  occasionally  pale  and  cold,  and  the  stomach  greatly 
oppressed ;  and  yet,  with  these  symptoms,  the  patient  com- 
plains of  an  intense  internal  heat,  and  of  unquenchable  thirst. 

In  many  instances,  the  stomach  is  particularly  irritable,  and 
all  iugesta  are  rejected,  and  with  it  sometimes  a  little  bile  or 
muco-serous  fluid,  and  possibly  a  little  blood ;  and,  as  in  the 
case  of  congestive  chill,  the  bowels  may  labor  under  a  sero- 
sanguineous  hemorrhage,  the  discharges  being  frequent  and 
greatly  prostrating.  The  respiration  is  difficult  or  labored,  be- 
ing quick  and  panting ;  the  pulse  is  feeble,  or  it  may  be  coi-ded, 
and  so  frequent  as  to  number  160  beats  per  minute.  Those 
who  have  practiced  in  the  cholera,  but  have  not  seen  this  form 
of  fever,  would,  upon  seeing  it,  suppose  it  to  be  the  former — it 
resembles  it  in  very  many  particulars.  The  preceding  symp- 
toms, with  modifications,  may  continue  two  or  three  days,  and 
unLss  relieved  will  terminate  in  death;  or,  if  not  too  oppres- 
sive, they  may  be  followed  by  a  remission,  or  even  an  inter- 


FEBRILE    FCEMS    OF   DISEASE.  115 

mission,  "when  the  same  symptoms  will  be  repeated  with 
increased  and  fatal  violence  when  the  proper  hour  is  brought 
about  by  the  revolution  of  its  type. 

In  a  majority  of  cases,  however,  these  dreadful  symptoms 
may  continue  but  a  few  hours,  before  they  are  replaced  by  a 
more  favorable  set,  as  returning  warmth  to  the  surface  and  ex- 
tremities— by  a  stronger  and  fuller  pulse ;  in  fine,  by  a  regu- 
larly-formed hot  stage,  which  as  to  mildness  will  be  in  the  ratio 
of  the  preceding  severity. 

Cause. — About  this  we  absolutely  know  nothing ;  but  a  few 
facts  have  been  observed  in  relation  to  it.  It  has  been  observ- 
ed in  some  places,  that  when  bilious  fever  prevailed  on  the 
table-lands,  this  form  took  place  or  was  produced  in  still  lower 
situations  near  the  river's  edge.  It  has  been  further  observed, 
that  when  remittents  and  intermittents  have  prevailed,  this  va- 
riety did  not. 

I)r.  Wood  is  of  the  opinion  that  it  is  a  miasmatic  fever,  but 
it  appears  to  us  rather  difficult  to  reconcile  this  idea  with  the 
prevalence  of  the  disease  through  the  winter,  as  is  sometimes 
the  case. 

Nature. — Dr.  Wood  asks :  "  What  is  it  that  imparts  its 
peculiar  character  to  the  pernicious  fever  ?  Can  it  be  inflam- 
mation ?"  He  appears  to  come  to  the  conclusion  that  it  is 
not — and  we  think  this  conclusion  is  very  correct.  He  then 
asks :  "  Is  congestion  the  source  of  danger  ?  I  can  not 
think  so." 

When  we  consider  the  cold  and  shriveled  condition  of  the 
extremities  and  surface  generally,  we  can  not  doubt  the  pres- 
ence of  congestion  even  to  an  alarming  extent.  We  care  not 
whether  the  danger  be  attributed  to  congestion,  or  to  the  ob- 
struction, for  the  removal  of  which  the  congestion  was  the 
first  preparatory  step,  because,  if  we  equalize  the  circula- 
tion, and  thereby  re-establish  depuration,  we  shall  remove  the 
disease.* 

*In  the  treatment  of  this  disease,  the  indications  are,  very  generally,  by 
the  Allopathic  faculty,  properly  judged  of,  but  their  therapeutics  are  defec- 
tive in  energy.  The  writer  has  witnessed  the  death  of  man}'  patients  from 
this  and  other  congestive  forms  of  disease,  simply  through  a  want  of  en- 
eivy.  To  melt  a  pig  of  iron  it  is  necessary  to  apply  heat,  but  to  expect  to 
melt  it  in  a  pile  of  sliavings  or  straw,  would  betray  a  remarkable  decree  of 
folly — not  more,  however,  than  most  physicians  manifest  with  regard  to 
congestive  forms  of  disease.  To  place  around  or  about  the  patient  a  few 
bottles  of  hot  water,  and  to  administer  to  him  a  little  toddy  and  a  little 
Ammonia,  is  equivalent  to  melting  a  pig  of  iron  with  straw. 

Through  a  similar  want  of  energy,  he  has  known  death  to  result  from 
coma.  Through  a  fear  of  public  opinion,  physicians  frequently  omit  ro  dis- 
charge their  own  convictions  of  duty — such  men  should  not  practice  medi- 
cine. An  illustration  of  this  may  not  be  out  of  place.  A  professional  ac- 
quaintance of  the  writer  had  a  case  of  coma,  and  after  having,  with  com- 
mendable zeal,  tried  all  the   means  to  arouse  his  patient  that  had  been 


116  FBBBILE   FORMS    OF   DISEASE. 

Treatment. — The  most  reliable  treatment  is  artificial  heat, 
together  with  counter-irritation,  most  energetically  adopted. 
The  most  active  and  powerful  means  must  be  applied  to  pro- 
cure a  determination  to  the  surface,  and  thereby  relieve  the  op- 
pressed condition  of  the  nervous  system,  as  well  as  the  conges- 
tion of  the  internal  viscera;  for  instance,  if  possible, the  Wiirm 
or  vapor-bath  may  be  used,  hot  foot-bath,  sinapisms  to  the 
whole  surface  of  the  inferior  extremities  and  spinal  column, 
having  previously  applied  powerful,  stimulating  liniments  with 
considerable  friction. 

As  to  internal  treatment.  Quinine  may  be  administered  in 
very  large  doses,  as  soon  as  possible,  without  regard  to  any 
particular  stage  or  period  of  the  disease ;  and  its  administration 
should  be  continued,  at  short  intervals,  until  a  decidedly  nor- 
mal impression  is  efiected. 

We  have  found  the  tincture  of  Gelseminum  given  in  connec- 
tion with  Quinine,  in  these  cases,  to  be  without  a  parallel  in 
efiicacy ;  it  must  be  given,  however,  until  its  peculiar  eti'ects 
are  in  luced,  which  may  be  known  by  an  inability  of  the  pa- 
tient to  raise  his  eyelids,  or  muscles  generally,  although  per- 
fectly conscious  of  all  around  him  ;  together  with  a  sense  of  in- 
creased temperature  of  the  surface,  a  return  of  the  skin  to  its 
normal  condition,  and  a  greater  degree  of  regularit}'-  and  soft- 
ness of  the  pulse.  In  addition  to  this,  the  various  preparations 
of  Xcinthoxylum,  the  bayberry  and  ginger  in  the  lorm  of  hot 
decoctions,  may  be  used  freely,  and  often  repeated. 

In  many  instances,  diarrhea  is  present,  and  the  discharges 
are  sometimes  hemorrhagic,  for  which  Geranin  may  be  given 
in  large  doses  in  conjunction  with  the  above  remedies  ;  but  if, 
on  the  contrary,  there  should  be  constipation,  active  doses  of 
Podophyllin  must  be  given  ;  and,  in  either  case,  as  soon  as  the 
condition  of  the  patient  will  permit,  a  combination  of  Podo- 
phyllin and  Leptandrin  should  be  administered,  at  short  inter- 
vals, lor  the  purpose  of  restoring  the  bilious  secretions  to  their 
normal  stan  lard. 

When  stupor  or  coma  is  present,  ice-cold  applications  must 
be  male  to  the  head,  in  connection  with  the  above  counter- 
irritating  means  to  the  spine  and  extremities,  and  stimula- 
ting enema  may  be  frequently  employed,  together  with  active 

recommended  by  authorities,  but  to  no  effect,  he  sent  for  counsel.  The 
consuUing  physician  suggested  actual  cautery  to  several  inches  square  of 
the  surface  on  the  lumbar  region  of  the  spine.  The  attending  physician 
refused  to  accede  to  it,  on  the  ground  that  the  patient  would  die  anyhow, 
and  if  such  a  measure  were  used,  the  people  would  say  that  they  had  killed 
him.  The  consulting  physician  then  requested  the  privilege,  upon  his  own 
responsibility,  which,  after  consultation  with  the  motner,  was  granted. 
Hence  tlie  cautery,  in  the  shape  of  a  hot  shovel,  was  applied — and  the  pa- 
tient saved.  In  this  instance,  but  for  the  energy  and  decision  which  every 
physician  should  possess,  the  patient  would  have  been  lost. 


FEBRILE  FOEMS   OF  DISEASE.  117 

doses  of  Podophyllin,  if  the  patient  can  be  made  to  swallow 
them. 

Cold  water  may  be  drank  freely  by  the  patient,  and  even  in 
large  quantities  it*  craved. 

After  the  disease  has  been  subdued,  the  treatment  during 
couvalescense  must  be  similar  to  that  already  recommended  in 
other  forms  of  fever. 

Species  YV .—Yellow  Fever — Typhus  Icterodes — Remitting 
Yellow  Fever — Bulam  Fever. 

This  is  another  form  of  fever  which  seems  to  be  produced  by 
a  longer  continuance  or  some  modification  of  that  cause  from 
which  the  other  forms  of  this  genus  result.  In  its  individual 
character  it  presents  many  and  considerable  extremes  of  varie- 
ty ;  so  much  is  this  the  case,  that  a  physician  introduced  to  it 
for  the  first  time,  would  be  strongly  induced  to  suspect,  in  a 
number  of  hospital  cases,  that  he  had  almost  as  many  indepen- 
dent forms  of  fever  to  contend  with.  Although  the  several 
patients  may  have  been  assailed  at  the  same  time,  yet  no  two 
of  them  will  have  the  same  symptoms,  in  the  same  order,  or 
manifested  in  the  same  manner.  Much  of  this  variety  must 
be  referred  to  inherent  ditferences  of  constitution  ;  and  some  of 
it,  no  doubt,  is  referable  to  the  magnitude  of  the  cause  of  the 
lesion  inflicted. 

The  prodromal  stage  or  period  partakes  largely  of  those  pe- 
culiarities which  attend  the  other  forms  of  fever.  In  the  pe- 
riod of  chill,  rigors  very  rarely  obtain,  and  in  some  instances 
there  is  not  even  an  appreciable  sensation  of  cold  or  chill — the 
hot  stage  being  gradually  merged  out  of  the  incipient,  which 
is  greatly  distinguished  by  the  severity  of  the  pain  in  the  back 
and  extremities.  The  stage  of  excitement  is  cliaracterized  by 
a  dry  and  hot  skin,  frequent  pulse,  a  flushed  face,  red  and  sui- 
fused  eyes,  and  a  hurried  respiration.  The  stomach  is  dis- 
turbed by  nausea,  and  possibly  by  some  vomiting,  as  both  are 
not  unfrequent  attendants.  Deglutition  is  frequently  rendered 
diflicult  by  the  soreness  of  the  fauces,  and  the  tongue  wears  a 
white  fur  in  conjunction  witli  considerable  moistm'e.  Gastric 
disturbance  is  often  present  from  the  beginning,  but  generally 
it  does  not  appear  until  after  the  lapse  of  twelve  or  eighteen 
hours,  when  it  becomes  exceedingly  troublesome — attended 
with  a  sense  of  burning  pain,  tension,  oppression,  and  soreness 
upon  pressure — all  ingesta  are  retained,  while,  singular  to  re- 
mark, its  own  morbid  contents  are  retained.  The  bowels,  as 
is  common  to  febrile  action,  are  constipated ;  flatulence  is  often 
troublesome,  and  the  desire  for  cold  drinks  is  very  imperious. 

Writers  generally  inlbrm  us  that  the  tongue  usually,  if  not 
always,  wears  a  pasty  coat,  but  Dr.  Gillkrist  says,  that  a  per- 


118  FEBRILE   FORMS    OF   DISEASE. 

fectly  clean  tongue  is  not  an  unfreqnent  attendant  upon  very 
severe  cases.  From  our  acquaintance  with  fever  in  general, 
we  are  disposed  to  regard  the  latter  as  a  more  unfavorable 
symptom  than  the  former.  He  adds,  that  the  most  character- 
istic symptom  of  this  fever  is  a  pasty  tongue,  with  the  tip 
and  edges  red.  In  young  and  vigorous  subjects,  the  skin  may, 
and  olten  does,  have  a  pungent  lieat,  but  we  are  not  to  sup- 
pose that  this  is  a  more  dangerous  symptom  than  even  a  much 
lower  temperature.  In  the  latter  case,  the  skin  has  a  peculiar 
condition — one  that  can  best  be  represented  by  the  idea  of 
compression  or  impaction,  which  is  by  no  means  to  be  regard- 
ed as  favorable.  The  patient  is  apt  to  sutler  much  irom  his 
incapacity  to  obtain  rest — he  is  restless — incessantly  tossing 
his  head  and  limbs  about — unable  to  sleep — he  is  deeply  dis- 
tressed— draws  deep  inspirations  ;  in  fine,  all  of  his  manifes- 
tations indicate  a  state  of  congestion — one  of  imperfect  reac- 
tion. 

The  uei'vous  symptoms  provoked  by  this  fever  are  surpassed 
by  no  otlier  class,  in  relation  to  the  suffering  they  produce. 
The  sev(re  pains  in  the  back  and  extremities  with  which  the 
alfectioB  was  introduced,  increase  and  continue  even  through 
the  stage  of  excitement ;  pains  in  the  head  and  eyes  usually 
attend,  are  generally  severe,  and,  like  the  former,  continue 
through  this  stage,  and  with  it,  all  of  them  so  increase  in  vio- 
lence as  to  cause  the  patient  to  moan  and  even  to  scream. 
The  mental  functions  are  frequently  deranged ;  sometimes  it 
amounts  only  to  confusion,  but  at  other  times  it  is  manifested 
by  maniacal  violence. 

As  the  disease  advances,  the  irritability  of  the  stomach  be- 
comes so  excessive  that  it  is  perfectly  useless  to  attempt  to  do 
anything  through  it  in  the  way  of  medication.  Dr.  Gillkrist 
(Cyc.  Prac.  Med.)  says:  "Our  experience  during  two  epidemics, 
one  in  the  West  Indies,  and  of  1828  at  Gibralter,  by  no  means 
bears  out  the  statement  of  others  as  to  the  bilious  appearance  of 
what  is  vomited  in  tiie  progress  of  this  fever ;  after  having 
paid  the  closest  attention  possible  to  this  point,  we  must,  on 
the  contrary,  state  that  with  the  exception  of  the  black-vomit 
stage,  and  at  the  very  commencement  of  the  attack,  what  is 
thrown  up  consists  of  the  ingesta  and  a  glairy  fluid.  Bile  is 
also  usually  absent  on  an  inspection  of  the  stools  and  urine." 
But  lit'  goes  on  to  remark,  that  it  should  be  remembered  that 
we  are  treating  of  a  disease  which  is  so  much  like  spasmodic 
cholera  as  to  lurnish  exceptions  to  almost  every  rule  that  can 
be  drawn  from  its  diversified  manifestations. 

Dr.  Eberle  says,  that  after  the  first  ejections,  bile  in  abun- 
dance is  irequently  bronght  up,  which  varies  in  color  from 
yellow  to  dark  green,  and  often  of  so  acid  a  quality  as  to  ex- 
coriate the  fauces. 


FEBKILE   FORMS    OF   DISEASE.  119 

The  stage  of  excitement,  with  occasional  rigors,  may  vary, 
says  Gillkrist,  in  its  duration  from  forty-eight  to  seventy-two 
hours ;  the  pulse  begins  to  give  way,  after  having,  up  to  this 
time,  been  lull,  rapid,  and  firm  ;  the  eyes  lose  their  brilliancy, 
and  the  patient,  in  most  insfauces,  becomes  exceedingly  feeble 
— too  much  so  to  sit  up  without  aid.  The  skin  becomes  cool- 
er and  moister,  the  respiration  calm,  and  the  stomach  measura- 
bly easy ;  the  severity  of  the  headache  and  other  pains  have 
departed,  and  the  patient  believes  himself  to  be  convalescent, 
and  such  may  even  be  the  fact ;  but  in  the  majority  of  cases 
the  struggle  is  yet  to  be  encountered. 

During  this  calm,  however,  we  are  not  without  indications 
of  the  existing  probability.  If  the  worst  is  yet  to  be  expected, 
the  epigastric  tenderness,  upon  pressure,  will  be  found  to  have 
increased,  and  instead  of  the  flushed  face  and  red  conjunctiva, 
we  will  find  an  orange  yellow  extending  from  the  face  to  the 
chest,  and  possibly  it  may  invade  the  entire  surface  ;  the  urine 
has  also  a  yellowish  tinge,  though  in  a  deep  quantity  it  may 
appear  brown,  and  the  pulse  has  fallen  below  the  normal  stan- 
dard. This  intermission  or  remission,  as  the  case  may  be, 
may  continue  only  a  few  hours,  or  it  may  continue  twenty- 
four.  But,  be  it  long  or  short,  it  is  succeeded  by  pain  in  the 
stomach  and  a  burning  sensation,  and  to  these  succeed  a  most 
distressing  vomiting ;  the  ejections  are  flocculent,  and  the  de- 
sire of  cool  drinks  urgent,  and  which,  as  soun  as  swallowed, 
are  rejected  with  a  force  that  leaves  no  doubt  as  to  the  extreme 
irritability  of  the  stomach.  These  symptoms,  having  contin- 
ued from  twelve  to  thirty-six  hours,  introduce  the  last  or  third 
stage. 

The  vomiting  now  becomes  almost  incessant,  and  the  mat- 
ter thrown  up  resembles  coflee-grounds  suspended  in  a  ghiiry 
liquid,  wliich  is  both  dark  and  ropy ;  the  pulse  sinks  in  force, 
volume,  and  frequency ;  the  tongue  is  dark,  approaching 
black  in  color;  the  burning  sensation  in  the  stomach  is  ex- 
tremely distressing ;  the  extremities  are  cold  and  clammy ; 
green  or  black  discharges  from  the  bowels  now  ensue ;  and 
then  follow  hiccough,  hemorrhages,  delirium,  coma,  convul- 
sions, and  death. 

This  is  perhaps  the  most  general  course  of  this  fever,  when 
fatal ;  but  it  must  be  remembered,  that  it  is  frequently  still 
more  overwhelming ;  the  patient  sometimes  falls  at  the  seizure 
as  though  felled  by  a  blow ;  and  in  some  it  commences  with 
furious  delirium.  In  such  cases,  it  is  common  for  the  disease 
to  terminate  fatally  at  the  close  of  the  third  day  ;  but  even  in 
these  cases,  dissolution  is  preceded  by  an  acrid  or  burning  sen- 
sation in  the  stomach  and  extending  to  the  esophagus.  The 
temperature  of  the  surface  and  extremities  falls  rapidly ;  the 


120  FEBRILE   FORMS   OF   DISEASE. 

features  shrink ;   the  urine  is  absent ;    distressing  singultus 
conies  on,  and  iinally  black  vomit. 

But  it  is  much  more  common  for  the  disease  to  be  protracted 
to  the  fifth,  sixth,  or  seventh  day,  and  sometimes  fatal  cases 
are  continued  to  the  twelfth  or  even  the  fifteenth  day.  The 
yellowishness  of  the  skin  frequently  appears  as  early  as  the 
third  day,  but  more  frequently  it  does  not  appear  until  a  more 
advanced  period,  and  in  a  few  instances,  not  at  all.  Hemor- 
rhages from  the  nose,  gums,  decayed  teeth,  and  every  other 
orifice  of  the  body  are  apt  to  appear  about  the  fourth  day. 

The  profession  are  generally  of  the  opinion  at  this  time  that 
the  matter  of  black  vomit  consists  of  coagulated  particles  of 
blood  suspended  in  gastric  mucus ;  it  is  insipid,  whereas  the 
black  vomit  of  bilious  or  typhous  fever,  when  it  occurs,  is  bitter. 
Causes. — The  time  has  been  when  this  subject  was  much 
discussed,  but  it  has  measurably  passed.  During  the  student- 
ship of  the  writer,  it  was  strenuously  maintained  by  some  to 
be  contagious.  Prof.  Hossack  told  the  writer  that  if  he  would 
hear  him  through  his  course  on  the  subject,  he  would  convince 
him  that  it  was  contagious  ;  he  did  so  attend,  but  was  not  con- 
vinced. Prof.  Caldwell  maintained  that  it  M'as  not  contagious 
— and  in  this  w^e  are  disposed  to  believe  that  he  was  cor- 
rect— but  he  also  maintained  that  it  was  produced  by  a  pecu- 
liar poison,  which  he  denominated  malarious  or  miasmatic. 
This  may  be  true,  but  the  writer  has  never  believed  it.  It  is, 
and  has  been,  his  opinion  that  the  various  forms  of  fever  em- 
braced by  this  genus  result  from  various  combinations  of  heat, 
humidity,  and  electricity  ;  but,  however  this  may  be,  the  weight 
of  the  profession  has  concurred  in  the  opinion  that  yellow  fever 
is  not  contagious,  and  in  this  we  think  an  important  point  has 
been  gained. 

We  do  not  intend  to  enter  into  any  discussion  of  the  subject 
in  this  place,  but  will  introduce  some  facts  which  may  possibly 
aid  others  to  think  for  themselves  upon  the  subject: 

1.  Yellow  fever  does  not  prevail  in  the  cold  season. 

2.  It  does  not  require  a  higher  temperature  than  79°  or  80° 
of  Fahrenheit. 

3.  It  is  arrested  by  cold,  heJxvy  rains  and  storms. 

4.  It  appears  simultaneously,  and  is  intermixed  wdtli  bilious 
remittents. — Eherte. 

6.  Dr.  Ramsey  states,  that  during  the  prevalence  of  the 
vellow  fever  at  Charleston,  in  South  Carolina,  in  the  year  1804, 
''"uclectcd  intermittents  frequently  terminated  in  yellow  fe- 
ver."— Ebcrh. 

6.  Dr.  Rush  also  states,  in  relation  to  the  yellow  fever  at 
Philadelphia,  in  1802,  "Intermittents,  the  mild  remittent, 
the  inflammatory,  bilious,  and  the  malignant  fever,  have,  in 
many  instances,  all  run  into  each  other." — Eherle. 


FEBRILE    F0EM3    OF   DISEASE.  121 

7.  Dr.  Caldwell,  in  speakiDg  of  the  yellow  fever  of  Phila- 
delphia, in  1803,  states :  "As  the  fever  receded  from  the  low 
ground  and  malignant  atmosphere  of  Water  street,  it  became 
more  and  more  manageable,  until  its  evanescent  shades  in 
SecoiM^street  were,  in  many  instances,  much  lighter  than  the 
common  remittent  of  the  country." 

8.  In  the  city  of  Baltimore,  "-the  bilious  or  vomiting  fever, 
in  its  ordinary  form,  prevailed  in  that  town  and  continued  un- 
til it  was  gradually  lost  in  the  severer  form  of  yellow  fever  as 
the  season  advanced." — {Danage)  Eberle. 

9.  "In  some  epidemics,  females  have  remained  wonderfully 
exempt ;  this  was  the  case  during  a  terrific  epidemic  at  Domi- 
nique and  Martinique,  in  1801." — Gillkrist. 

10.  In  1811,  at  Xeres,  females  "sufiered  in  a  particular  man- 
lier."— Gillkrist. 

11.  Negroes  are  known  to  be,  generally,  very  insusceptible 
to  the  cause  of  this  disease. 

"We  have  in  another  place  shown  why  it  is  that  women  and 
children  are  measurably  exempt  from  any  form  of  fever  to 
which  the  other  sex  is  peculiarly  liable.  This  fact  can  not  be 
explained  by  assuming  any  modification  of  the  poison,  if  such 
it  be.  We  have  also  explained  why  it  is  that  negroes  are  but 
little  liable  to  the  southern  fevers. 

Yellow  fever  is  sometimes  produced  under  circumstances  en- 
tirely incompatible  with  the  idea  of  a  malarious  poison.  Dr. 
Gillkrist,  upon  this  subject,  says :  "In  fairness,  we  can  not 
think  that,  like  many  other  places  which  may  be  mentioned 
where  yellow  fever  is  known  from  time  to  time  to  appear,  it 
can  not  be  admitted  that  Gibralter  furnishes  sources  from  which 
malaria,  in  the  usual  sense  of  that  word^  arises,  sufiicient  to 
account  for  the  appearance  of  a  malignant  fever ;  neither  can 
we  concede  to  authorities  of  great  respectability,  that  either 
there  or  in  various  other  places  the  solution  of  the  question  is 
to  be  found  in  a  crowded  population,  the  filth  of  the  town,  or 
the  state  of  the  sewers. 

"If  we  consider  the  soil  and  elevation,  it  must  be  admitted 
that  here,  too,  no  satisfactory  conclusion  can  be  drawn  ;  for  if 
we  find  evidence,  especially  in  the  West  Indies,  and  on  the 
American  continent,  of  the  influence  of  a  marshy  soil,  on  sev- 
eral occasions,  this  does  not  hold  good  in  other  instances ;  and 
in  those  countries,  as  well  as  in  Spain,  many  places  might  be 
mentioned,  where  elevation,  soil,  etc.,  would  seem  to  guaran- 
tee immunity,  but  where,  nevertheless,  the  disease  occasionally 
prevails  to  a  devastating  extent." 

If  we  had  space  to  enter  fully  into  this  subject,  it  would  be 
discovered  that  all  the  facts  which  favor  the  doctrine  of  mala- 
rious  poison,  equally  favor  our  own  views,  and  that  those 
8 


122  FEBKILE    FORMS    OF  DISEASE. 

which  are  fatal  to  that  hypothesis,  are  entirely  compatible  with 
ours. 

If  yellow  fever  be  caused  by  miasm,  it  is  supposed  that  it 
must  in  some  way  be  associated  with  the  decomposition  of  ani- 
mal matter,  because  the  disease  is  confined  to  cities,  armies, 
ships,  etc.  The  disease  is  never  known  in  l^ew  Orleans  when 
the  river  keeps  full  during  the  hot  season ;  and  when  it  be- 
comes low,  there  is  exposed  an  immease  mud-bar  through  the 
whole  extent  of  the  city's  front,  in  which  was  deposited,  during 
the  business  season,  an  immense  quantity  of  animal  matter. 
Underi^uch  circumstances,  is  it  not  possible  that  the  atmos- 
phere may  generate  a  species  of  animalculse  which  may  be  in- 
haled, and  thus  produce  the  disease  ?  Or,  in  lieu  of  this,  may 
it  not  cause  their  generation  in  the  human  system  ?  Dr.  Khees, 
of  Philadelphia,  states :  "  When  the  matters  fresh  thrown  from 
the  stomach  were  examined,  the  animalculse  werQ  alive  and  in 
constant  motion  ;  but  that  no  such  phenomena  could  be  detected 
in  autumnal  or  bilious  fevers."  This  circumstance  demon- 
strates the  existence  of  a  very  great  difference  between  the  two 
varieties  of  fever. 

Diagnosis. — All  fevers,  in  their  initiatory  stage,  have  so 
many  features  in  common,  that  it  is  difficult  to  distinguish  this 
from  other  febrile  forms  under  two  or  three  days,  and  yet  there 
are  signs  which  may  guide  to  a  very  probable  conclusion,  such 
as  the  turbid  conjunctiva,  the  great  severity  of  the  pain  in  the 
loins  and  inferior  extremities,  and,  when  the  malady  has  fur- 
ther advanced,  the  great  epigastric  tenderness  and  the  gasti-ic 
irritability,  the  regular  continuance  of  the  fever  for  two  or 
three  days,  and  then  succeeded  by  an  abatement — intermission 
or  remission,  the  yellowishness  of  the  eyes  and  skin,  and 
finally  the  appearance  of  the  black  vomit.  If  yellow  fever 
prevails  at  the  time,  or  if  the  other  usually  attending  circum- 
stances of  the  disease  be  present,  the  preceding  symptoms  can 
scarcely  leave  a  reasonable  doul3t  as  to  the  character  of  the 
disease. 

Prognosis. — This  has  hitherto  most  generally  proved  to  be 
a  very  fatal  form  of  disease,  having  its  fatality  sometimes  to 
run  as  high  as  ninety-five  per  centum.  We  feel  quite  sure  that 
such  a  fatality  is,  in  a  great  measure,  due  to  the  prevailing  ig- 
norance of  its  pathology  and  requisite  therapeutics. 

It  is  now  a  well  settled  fact,  that  the  disease  is  attended  with 
a  much  more  extensive  mortality  when  it  first  appears  than  at 
any  subsequent  period — that  its  fatality  declines  from  the  be- 
ginning of  the  epidemic  to  its  clo=e  ;  and  from  this  circumstance 
it  appears  to  be  generally  inferred,  that  the  cause,  whatever  it 
may  be,  is  more  concentrated  or  capable  of  inflicting  disease 
than  it  becomes  to  be  at  a  later  period.  We  regard  this  inference 
as  being  true  only  to  a  small  extent,  if  at  all.     Our  conclusion  is, 


FEBRILE  FOKMS    OF  DISEASE.  123 

t"hat  tlae  cause,  when  it  becomes  first  introduced,  cuts  down  all 
of  the  most  vulnerable  to  its  influence,  and  as  the  vulnerability 
diminishes,  so  do  its  fatality  and  the  number  of  its  victims. 
Dr.  Wood  says :  "  Fei'haps  the  general  average  of  deaths  from 
yellow  fever,  prevailing  epidemically,  may  be  stated  at  one- 
third." 

Among  the  unfavorable  symptoms.  Dr.  Wood  cites  the  fol- 
lowing :  Excrutiating  pains  in  the  forehead,  back,  and  limbs ; 
great  frequency  and  fullness  of  the  pulse,  a  gaseous  state  of  it, 
or  its  entire  absence  at  the  wrist ;  a  blood-shot  appearance  of 
the  conjunctiva,  and  a  bronzed  or  mahogany-color  of  the  skin ; 
a  short  and  violent  febrile  stage ;  coma  or  convulsions ;  a  slow 
respiration  with  deep  sighs  ;  hiccough  ;  excessive  restlessness, 
and  a  disposition  to  get  out  of  the  bed  and  walk  ;  an  unnatu- 
ral apathy,  or  an  expression  of  dogged  indifference  in  the  ad- 
vanced stages ;  a  voracious  appetite  ;  suppression  of  urine  ;  an 
universal  hemorrhagic  tendency,  with  petecchise ;  and  finally, 
the  occurrence  of  the  black  vomit.  This  last  symptom  is  re- 
garded  as  almost  necessarily  fatal,  but  occasional  recoveries 
are  mentioned  by  authorities  as  having  taken  place  after  its  ap- 
pearance. 

Indications. — ^Whatever  the  cause  may  be  can  matter  but 
little  when  we  know  the  absolute  condition  of  the  system,  and 
that  this  is  one  of  a  high  order  of  congestion  there  can  be  en- 
tertained no  reasonable  doubt.  The  indications  then,  must  be 
to  overcome  all  cutaneous  stricture  and  stimulate  its  surface, 
and  by  revulsives  to  produce  a  centrifugal  action  in  the  circu- 
lation— in  other  words,  our  duty  is  to  equalize  the  circulation, 
and  to  establish  and  maintain  depuration. 

Tkeatment. — In  the  early  stage  of  the  disease,  should  there 
be  no  irritability  of  the  stomach,  an  emetic  must  be  given,  to 
be  followed  by  an  active  cathartic,  for  which  the  Compound 
Powder  of  Jalap  is  admirably  adapted  ;  after  the  operation  of 
the  cathartic,  the  Compound  Powder  of  Ipecacuanha  and 
Opium,  combined  with  equal  parts  of  Quinine,  may  be  given 
every  hour  or  two  in  three  or  four-grain  doses  ;  and  the  bowels 
must  be  kept  open  daily,  in  every  case,  by  small  portions  of 
Podophyllin  and  Leptaudrin,  frequently  administered ;  but  in 
cases  of  irritability  of  the  stomach,  in  which  everything  is  re- 
jected from  it.  Mustard  must  be  applied  over  the  epigastric  re- 
gion, and  energetic  counter-irritation  to  the  spinal  column  and 
inferior  extremities,  together  with  active  cathartic  injections, 
combined  with  pulverized  Lobelia  or  a  portion  of  Tincture  of 
Lobelia  and  Capsicum.  The  patient  may  also  eat  ice  in  proper 
quantities,  which  will  usually  be  found  to  assist  in  overcoming 
the  gastric  irritability. 

The  surface  of  the  body,  in  all  instances  of  this  disease,  and 
especially  when  gastric  irritability  is  present,  should  be  closely 


1^4  FEBRILE   FOEMS    OP   DISEASE. 

attended  to,  the  whole  surface  should  very  frequently  be  bathed 
with  a  cold  alkaline  wash,  which  should  be  continued  until  the 
temperature  is  much  diminished,  and  renewed  whenever  there 
is  an  increase  of  fever.  In  other  respects,  pursue  the  same 
course  as  laid  down  for  congestive  fever.  Cold  water  may  be 
allowed  whenever  the  patient  craves  it,  but  should  it  be  almost 
immediately  rejected,  small  portions  of  ice  should  be  substi- 
tuted. 

Species  Y. — Lifantile  Eemittent  fever. 

We  have  concluded  not  to  separate  this  form  of  fever 
from  the  general  subject,  as  nothing  could  be  gained  by  so 
doing. 

This  species  has  been  divided  into  three  varieties :  the  acute, 
slow,  and  low — and  the  differences  between  them  are  sufficient- 
ly considerable  to  justify  the  distinction. 


Yabiety  I. — Acide  Infantile  Remitteni. 

This  form  is  distinguished  by  pain  in  the  head  and  abdo- 
men, slimy  stools,  little  thirst,  loss  of  appetite,  drowsy  exacer- 
bations, and  wakeful  remissions ;  it  begins,  usually  by  several 
days,  with  marked  symptoms  of  indisposition ;  the  patient's 
color  is  changed ;  its  expression  contra-indicates  health ;  its 
breath  is  offensive ;  it  picks  its  nose  and  lips  ;  has  a  dry  cough, 
anorexia,  swollen  abdomen,  and  flatulence ;  it  grates  its  teeth, 
moans  and  starts  in  its  sleep ;  its  urine  is  turbid,  and  upon 
cooling  it  deposits  a  whitish  sediment ;  and  its  bowels  may  be 
either  loose  or  costive.  In  the  midst  of  these  symptoms  a 
chill  is  produced,  which  is  soon  followed  by  fever ;  but  some- 
times its  beginning  is  sudden,  and  no  introductory  stage  be- 
comes apparent. 

Of  the  paroxysms  there  are  frequently  three  in  twenty-four 
hours — one  in  the  forenoon,  one  in  the  atternoon,  and  one  at 
night,  which  is  usually  the  most  intense.  It  is  hot  and  of 
course  restless  at  night,  and  the  diurnal  exacerbations  soon 
succeed.  When  the  fever  is  severe,  the  remissions  are  short, 
and  frequently  not  more  than  observable ;  it  is  attended  by 
troublesome  flatulence,  an  increased  cougli,  a  hurried  respira- 
tion, and  occasionally  by  nausea  and  vomiting.  As  the  lever 
progresses,  the  exacerbations  increase,  and  all  of  its  attendant 
symptoms  become  aggravated,  so  that  the  pulse  runs  from  140 
to  160. 

At  length,  all  the  symptoms  during  the  remissions  abate ; 
it  begins  to  rest  composedly ;  the  pulse  is  reduced  to  120  or 
130  per  minute ;  it  is  more  wakeful,  gives  more  attention  to 
passing  events,  and  is  not  unfrequently  playful.     In  the  ex- 


FEBKILE   FOEMS  OF   DISEASE.  125 

aeerbations  and  remissions  the  skin  is  usually  dry,  and,  when 
an  exception  occurs,  the  moisture  is  usually  confined  to  the 
head,  breast,  or  palms  of  the  hands.  As  yet,  neither  food  nor 
drink  is  desired,  and  when  either  is  taken  it  is  usually  rejected 
as  soon  as  swallowed.  The  urine  has  become  limpid  and  of  a 
high  color,  and  the  stools  never  have  a  normal  appearance  in 
smell,  color,  or  consistence ;  worms  are  sometimes  found  in  the 
stools  and  vomitings,  and  they  spontaneously  appear  through 
the  anus  or  the  mouth ;  the  exacerbations  become  milder  and 
more  abridged  as  the  pyrexia  declines  ;  moisture  generally  ap- 
pears upon  the  surface ;  the  pulse  falls ;  the  appetite  and  re- 
freshing sleep  return ;  a  copious  sediment  deposits  from  the 
urine,  and  the  alvine  excretions  have  become  more  healthy. 
The  complaint  continues  from  one  to  three  weeks,  and  occasion- 
ally longer. 

Vaeikty  II. — Slow  Infantile  Remittent. 

There  is  a  variety  of  infantile  remittent  which  makes  its  as- 
sault more  insidiously  and  imperceptibly,  and  by  way  of  dis- 
tinction it  is  called  the  slow  variety.  In  this  form  the  breath 
is  offensive,  the  appetite  is  fastidious,  the  abdomen  frequently 
enlarged,  and  the  flesh  is  gradually  wasted  ;  it  has  but  one  ex- 
acerbation, which  comes  on  in  the  evening,  continues  until 
morning,  and  is  then  succeeded  by  a  profuse  perspiration ; 
hectic  flushings  are  frequent  through  the  day,  the  skin  is  dry 
and  harsh,  the  pulse  about  140  in  the  exacerbation,  and  about 
100  in  the  remission.  The  patient  is  rarely  so  much  indis- 
posed as  to  be  confined  to  bed ;  nevertheless,  it  is  not  inclined 
to  be  active  or  playful,  but  is  indolent,  listless,  and  complains 
of  an  aching  of  the  limbs  when  motion  is  attempted.  It  is  of- 
ten considerably  disposed  to  doze  both  day  and  night ;  to  pick 
its  nose  ;  the  urine  is  of  a  deep  orange  color ;  the  thirst  is  but 
little  ;  the  appetite  is  absent ;  the  tongue  is  white  and  moist, 
and  the  stools,  as  in  the  former,  or  acute  variety,  are  unnatu- 
ral. At  the  commencement  of  a  favorable  termination,  all  the 
symptoms  abate,  and  health  and  cheerfulness  return.  The  con- 
tinuance of  this  form  of  disease  may  be  of  two  or  three  months. 

Yaeiety  III. — Loio  Infantile  Remittent. 

This  form  resembles  very  closely,  for  the  first  week,  the 
acute  variety,  except  that  it  beghis,  pretty  uniformly,  in  a  sud- 
den manner,  and  afflicts  the  brain  more  severely,  often  to  the 
production  of  delirium.  Its  peculiar  character  now  com- 
mences by  an  exhibition  of  indifference  to  all  that  surrounds 
it ;  it  calls  for  nothing,  and  yet  refuses  neither  food  nor  drink 
when  presented  to  it;  the  superior  extremities  are  usually, 


I2ff  FEBEILE   FOKMff  OF   DISEASE. 

during  its  waking  hours,  kept  in  constant  motion,  while  its  in- 
ferior continue  in  a  fixed  postnre.  When  the  disease  has  at- 
tained to  its  most  oppressive  stage,  such  is  the  debility  that  the 
patient  loses  the  power  of  speech,  and  its  jaws  occasionally 
become  fixed  and  immovable.  During  the  exacerbations  it 
elumbere  much;  the  eyes  are  dull,  inattentive,  and  flushed 
when  the  stage  begins  ;  the  tongue,  teeth,  and  lips  are  covered 
with  a  blackish  fur ;  the  facial  expression  betrays  much  dis- 
tress, and  during  the  remissions  much  restlessness  becomes  ap- 
parent by  the  constant  motion  of  its  arms.  Before  a  discharge 
©f  faeces  or  flatus,  it  becomes  restless,  and,  tlK)ugh  sensible, 
the  cystic  and  alvine  excretions  are  passed  involuntarily. 
In  the  remission,  the  pulse  is  about  100,  but  in  the  exacerba- 
tion it  rises  to  120.  When  the  exacerbations  become  shorter 
and  milder,  a  favorable  turn  is  supposed  to  have  commenced, 
and  if  so,  the  drowsiness  will  be  reduced,  the  eyes  will  become 
clearer,  the  expression  more  placid,  the  pulse  more  calm,  the 
tongue  more  clean,  and  the  appetite  improved;  it  gradually 
becomes  to  betray  some  fretfuluess,  the  speech  and  voice  re- 
turn, but  the  urine  is  still  passed  involuntarily — weakness  is 
the  only  matter  of  complaint,  and  this  is  finally  overcome. 
This  form  may  continue  six  weeks,  or  even  longer. 

Causes. — Upon  this  subject  tliere  has  existed  considerable 
contrariety  of  ©pinion.  At  one  time  it  was  attributed  by  many 
to  the  presence  of  worms ;  so  much  so  was  this  the  opinion 
thatHofiman  was  greatly  surprised  when  he  did  not  find  worms 
in  connection  with  this  disease.  At  that  day  the  disease  was 
familiarly  called  "worm  fever."  Something  like  a  hundred 
years  since,  an  Edinburgh  physician  questioned  the  doctrine, 
and  showed  that  worms  were  not  always  the  cause  of  this  fe- 
ver. Dr.  Butter,  in  1782,  in  his  work  on  this  fever,  attributed 
the  disease  to  debility,  derangement,  etc.,  of  the  digestive  or- 
gans. He  was  of  the  opinion,  however,  that  worms  were  of 
advantage  to  the  system — and  even  Dr.  Rush  was  much  in- 
clined to  the  same  view  of  the  subject.  At  the  present  time, 
the  profession  is  generally  of  the  opinion  that  Butter's  views, 
in  the  main,  are  correct.  In  France,  it  is  considered  as  a  spe- 
cies of  gastro-enteritis.  It  occurs  both  sporadically  and  epi- 
demically. In  the  latter  form,  it  is  produced,  probably,  in  or- 
ganically liable  constitutions,  by  some  of  the  usual  causes  of 
fever.  Dr.  Sims  reports  one  epidemic  of  it  as  prevailing  sim- 
nltaneously  with  a  low  grade  of  nervous  fever  among  adults 
(Cy.  Frac.  Med.). 

Diagnosis. — Dr.  Sims,  above  cited,  was  of  the  opinion  that 
it  was  impossible  to  distinguish  this  fever  from  hydrocephalus 
in  patients  under  five  years  of  age ;  but  Pemberton  is  of  a 
contrary  opinion.  He  thinks,  that  the  screaming  of  the  pa- 
tient during  sleep,  strabismus,  tossing  of  the  hands  over  the 


FEBKILE    FORMS    OF   DISEASE.  127 

head,  intolerance  of  light,  and  the  disturbed  condition  of  the 
intellectual  faculties,  which  characterize  hydrocephalus,  will 
distinguish  it  from  this  form  of  fever,  in  which  there  is  no 
strabismus,  no  derangement  of  the  intellectual  faculties,  and 
but  very  seldom  any  screaming  during  sleep  or  any  intoler- 
ance of  light.  Furthermore,  says  Dr.  Golis,  hydrocephalus  is 
attended  by  no  distinct  stages,  its  pulse  never  falls  below  the 
normal  standard,  and  it  never  extends  from  three  to  six  weeks. 

Peognosis. — Although  this  is  a  troublesome  and. tedious  dis- 
ease, it  can  not  be  thought  very  liable  to  any  unfavorable  ter- 
mination, more  particularly  under  a  judicious  practice.  In  fatal 
cases  the  intestines  have  been  found  greatly  distended  and  the 
mesenteric  glands  somewhat  enlarged,  but  neither  inflamma- 
tion nor  effusion  has  been  detected  in  the  abdominal  cavity. 
The  fact  that  this  fever  is  somewhat  liable  to  pass  into  hydro- 
cephalus, constitutes  its  most  dangerous  feature.  When  such 
a  tendency  exists,  it  is  usually  indicated  by  sickness  and  vom- 
iting in  the  beginning. 

Treatment. — At  the  commencement  of  the  disease,  when 
the  stomach  is  loaded  with  undigested  food,  or  before  gastric 
irritation  has  taken  place,  a  light  emetic  will  usually  be  found 
advantageous.  This  should  be  followed  by  an  active  purga- 
tive, as  the  Compound  Powder  of  Jalap,  which  is  probably  the 
best  agent  that  can  be  used,  often  exerting  a  beneficial  influ- 
ence over  the  disease  sufficient  either  to  put  an  end  to  it  at 
once,  or  greatly  mitigate  its  subsequent  severity. 

After  the  bowels  have  been  freely  acted  upon,  should  the  fe- 
ver continue,  small  doses  of  Leptandrin,  with  or  without  Podo- 
phyllin,  or  if  there  be  gastric  acidity,  Leptandrin  combined 
with  the  Compound  Powder  of  Rhubarb,  or  Syrup  of  Rhubarb 
and  Potassa,  should  be  administered  in  doses  sufficient  to 
cause  one,  but  not  to  exceed  two  daily  evacuations  from  the  bow- 
els ;  and  in  cases  of  excessive  irritability  of  the  stomach,  in 
which  these  agents  are  rejected,  active  cathartic  injections  must 
be  used. 

Gastric  irritability  may  be  overcome  by  mild  mucilaginous 
draughts  of  a  diuretic  nature,  as  Marsh- Mallows,  to  be  aided 
by  external  applications,  as  sinapisms  to  the  epigastric  region 
and  spinal  column.  Spasmodic  action  will  usually  yield  to  the 
Tincture  of  Lobelia  and  Capsicum,  aided  by  warm  baths,  espe- 
cially if  it  amounts  to  actual  convulsions.  Probably  the  Tinc- 
ture of  Gelseminum  might  be  of  service  when  these  symptoms 
are  present.  When  great  determination  to  the  head  is  mani- 
fest, cooling  lotions  must  be  frequently  applied,  together  with 
warmth  and  counter-irritation  to  the  inferior  extremities  and 
spinal  column. 

As  soon  as  the  stomach  can  retain  medicine,  anti-periodic3 
must  be  given  continuously  every  few  hours,  until  the  solution 


128  ^  FEBKILE   FORMS    OF   DISEAS'E. 

of  the  disease  ;  the  followiug  is  perhaps  equal,  if  not  superior, 
to  any  other  for  this  purpose : 

R.     Powder  of  Ipecac,  aijji  Opium,  9ss, 
S.  Quinine,  9j.     Mix, 

Divide  into  ten  powders,  and,  to  a  child  two  years  old,  give 
one  powder  every  four  or  five  hours. 

As  soon  as  convalescence  takes  place,  the  mild  bitter-tonics, 
as  Hydrastin,  Cornin,  etc.,  must  be  given,  and  their  use  con- 
tinued, until  the  strength  and  appetite  are  restored.  The  diet 
must  be  very  light,  and  increased  as  the  restoration  to  health 
advances.  Oftentimes,  when  this  disease  is  very  obstinate,  a 
removal  to  the  country  or  change  of  climate  will  eflect  an  im- 
mediate beneficial  result. 


TYPHOID  AND  TYPHOUS  FEYERS, 

We  here  present  to  our  readers  the  investigations  of  Dr,  W, 
Jenner,  in  relation  to  these  two  febrile  forms  of  disease,  which 
we  regard  as  an  excellent  analysis,  and  of  much  value  to  the 
practitioner : 

On  Tyj>hoid  and  Typhoits  Fevers.  An  attemiH  to  Deter- 
7nine  the  Question  of  the  Identity  or  ]Von-Ide?itity,  hy  an 
Analysis  of  the  Syivptoms^  and  of  the  Ajpjpearances  found 
after  Death^  in  Sixty-Six  Fatal  Cases  of  Continued  Fever., 
observed  in  the  London  Fever  Hospital .,  from  Jamiary.,  1847, 
to  February.,  1849,  By  W,  Jenner,  M.  D.,  Professor  of  Patho- 
logical Anatomy  in  University  College,  London. — This  is  the 
title  of  an  extremely  interesting  paper  which  has  been  publish- 
ed in  successive  numbers  of  the  Monthly  Journal  of  Medical 
Science,  commencing  in  the  number  for  April  of  last  year,  and 
concluded  in  the  number  for  April  of  the  present  year.  It 
constitutes  one  of  the  most  important  contributions  to  the  his- 
tory of  continued  fever  that  has  yet  been  made,  presenting,  as 
it  does,  the  carefully  recorded  histories  of  a  very  large  number 
of  cases,  admirably  arranged  and  analyzed,  by  a  highly  com- 
petent and  reliable  observer. — Amer.  Jour.  Med.  Sci.,  for 
1850. 

''^  Age. — Typhoid  fever  was  limited,  in  the  cases  here  con- 
sidered, to  persons  under  40  years  of  age ;  nearly  one-third 
of  the  forty-three  cases  of  typhous  were  more  than  50  years 
of  age. 

'■^  Mode  of  attack. — As  a  general  rule,  the  attack  of  typhoid 
fever  commenced  more  insidiously  than  that  of  typhous  fever. 


FEBEILE    FOEMS    OF   DISEASE.  129 

This  observation,  like  all  others  in  this  paper,  applies,  of  course, 
only  to  fatal  cases. 

''''Duration. — The  average  duration  of  the  fatal  cases  of  ty- 
phoid fever  was  22  days.  Of  the  fatal  cases  of  typhous  fever, 
14  days.  Half  the  cases  of  typhoid  fever  survived  to  the  20th 
day  of  the  disease.  Not  a  single  case  of  typhous  fever  sur- 
vived the  20th  day  of  disease. 

"  Eruption. — Tlie  difference  in  the  appearance  of  the  erup- 
tion in  the  two  diseases  was  as  great  as  it  well  could  be,  con- 
sidering that  both  were  of  a  reddish  hue. 

"  Miliary  vesicles  and  sudarnina. — These  vesicles  were  pre- 
sent in  an  equal  proportion  of  the  cases  of  both  diseases  under 
40  years  of  age.  But  in  no  cases  of  typhous  fever,  more  than 
40  years  of  age,  were  they  detected. 

"Subsequent  experience  leads  me  to  believe  that  miliary 
vesicles  are  rarely  seen  on  individuals  more  than  40  years  of 
age ;  and  very  rarely,  indeed,  if  ever,  on  patients  more  than 
50  years  old.  I  have,  during  the  last  year — ^.  ^.,  since  my 
attention  was  directed  to  this  point — seen  these  bodies  on  no 
one  of  the  many  patients  more  than  50  years  of  age,  laboring 
under  various  diseases,  that  have  come  under  my  observation. 

"  Expression^  manner.,  hue  of  face.,  etc. — As  the  rule,  in 
the  cases  of  typhoid  fever  here  analyzed,  the  expression  was 
much  less  indicative  of  prostration,  and  more  anxious,  than  in 
cases  of  the  typhous  fever.  In  the  former  disease,  the  com- 
plexion was  tolerably  clear,  and  the  flush,  when  present,  was 
of  a  bright-pinkish  color,  limited  to  one  or  both  cheeks,  and 
often  distinctly  circumscribed.  In  typhous  fever,  on  the  con- 
trary, the  complexion  was  thick  and  muddy,  the  flush  of  the 
face  uniform,  and  of  a  dusky-red  color. 

"  Headache  w^as  a  constant  symptom  in  all  the  cases  of 
typhoid  and  typhous  fevers ;  but  it  disappeared  about  the 
10th  or  12th  day  in  the  latter,  and  not  until  the  termination  of 
the  second,  or  the  middle  of  the  third  week,  in  the  former. 

"  Delirium  commenced  in  three  only  of  ten  cases  of  typhoid 
fever  before  the  14th  day ;  while  it  began  in  iburteen  out  of 
fifteen  cases  of  typhous  fever  before  the  14th  day.  As  a 
rule,  the  delirium  was  decidedly  more  active  in  typhoid  than 
in  typhous. 

''''  tiomnolence. — In  eight  out  of  nine  cases  of  typhoid  fever, 
somnolence  commenced  after  the  14th  day  of  disease.  In  sev- 
enteen out  of  eighteen  cases  of  typhous,  before  the  termination 
of  the  second  week. 

"  Coma-vigil. — One-fifth  of  the  cases  of  typhous  fever  expe- 
rienced coma-vigil ;  not  a  single  case  of  tj'^hoid  -fever  expe- 
rienced that  condition. 

'•  Spasmodic  movements  were  nearly  equally  frequent  in  the 
two  diseases. 


130  FEBBILE   FOEM8    OF   DISEASE. 

'•^  Retention  of  urine  and  involuntary  discharge  of  urine 
and  stools  occurred  with  equal  frequency  in  the  two  dis- 
eases ;  but  at  a  much  earlier  date  in  typhous  than  in  typhoid 
fever. 

''^  Loss  of  muscular  power. — Little  more  than  a  fourth  of 
the  patients  attacked  with  typhoid  fever  kept  their  beds  en- 
tirely before  the  seventh  day  of  disease.  All  the  patients 
aflected  with  typhous,  whose  cases  are  here  considered, 
took  altogether  to  their  beds  before  the  seventh  day  of  the 
disease. 

"The  prostration  was  rarely  so  extreme  in  the  cases  of 
typhoid  fever  as  in  those  of  typhous  fever.  Extreme  prostra- 
tion, when  it  did  occur  in  typhoid  fever,  was  not  observed  until 
from  the  14th  to  the  30th  day,  while  in  a  large  majority  of  the 
cases  of  typhous  fever  it  was  marked  between  the  9th  and  12th 
day  of  disease. 

"  Epistaxis  was  present  in  five  of  fifteen  cases  of  typhoid  fe- 
ver— ^in  not  one  of  twenty-three  cases  of  typhous  fever. 

'"''Hearing  was  equally  and  similarly  aflected  in  the  two  dis- 
eases. 

"  Eyes. — The  conjunctivae  were  very  much  more  constantly 
and  intensely  injected  in  the  cases  of  typhous  than  in  those  of 
typhoid  fever ;  the  pupils  were  absolutely  larger  than  natural 
in  a  majority  of  the  cases  of  the  latter  disease,  while  these  were 
abnormally  contracted  in  a  large  majority  of  the  cases  of  the 
former  affection. 

"  Tongue. — Although  individual  cases  of  the  two  forms  of 
disease  may  have  closely  resembled  each  other  in  the  appear- 
ance of  the  tongue,  yet,  taking  the  whole  of  either  group  ot 
cases,  this  organ  presented  a  singularly  different  aspect  in  the 
one  from  what  it  did  in  the  other.  It  was  much  more  frequent- 
ly moist  throughout  the  disease  in  typhoid  than  in  typhous  fe- 
ver. When  dry,  it  was  often  red,  glazed,  and  fissured,  in  the 
former ;  but  rarely  so  in  the  latter. 

"Again,  in  typhoid  fever,  when  the  tongue  was  brown,  its 
hue  was  much  less  deep — ^it  was  of  a  yellowish,  instead  of  a 
blackish  brown.  The  small,  dry  tongue,  with  red  tip  and 
edges,  smooth,  pale,  brownish-yellow  fur,  fissured — the  surface 
seen  between  the  fissures  being  red — may  be  considered  differ- 
entially as  a  diagnostic  sign  of  typhoid  fever.  One  only  of  the 
twenty  patients  affected  with  the  typhoid  fever,  but  eight  of  the 
forty  patients  laboring  under  typhous  fever,  were  unable  to  ob- 
trude the  tongue  when  bidden.* 

''''Intestinal  hemorrhage  occurred  in  one-third  of  the  patients 


"  *  This  clearly  indicates  the  difference  in  the  amount  of  prostration  in 
the  two  diseases. 


FEBBILE    FOKMS    OF   DISEASE.  131 

laboring  under  typhoid  fever — in  none  of  those  suffering  from 
typhous  fever.* 

''  The  other  abdominal  symptoms  and  signs  need  no  recapit- 
ulation.     ^ 

"  Appetite  and  thirst. — jSTo  difference  in  the  two  diseases. 

"  Pulse. — ^The  frequency  of  the  pulse  fluctuated  much  more, 
from  day  to  day,  in  the  case  of  typhoid  than  in  those  of  typhous 
fever.  ' 

"  Cough  and  physical  chest-signs — Sonorous  rale  was  very 
much  more  frequently  present  in  the  cases  of  typhoid  than  in 
those  of  typhous  fever — i.  d.,  it  was  present  in  eleven  out  of 
twelve  cases  of  the  former,  and  in  seven  only  of  twenty- 
one  cases  of  the  latter.  Dullness  of  the  most  depending  part 
of  the  chest,  Irom  intense  congestion  of  the  lung,  was  ob- 
served in  nine  cases  of  typhous  fever — in  no  case  of  typhoid 
fever. 

"  Sloughing  appeared  to  be  nearly  equally  frequent  in  the 
two  diseases. 

"  Erysipelas  occurred  in  seven  of  the  twenty-three — i.  e.^  in 
nearly  a  third  of  the  cases  of  typhoid  fever ;  and  in  two  only 
of  the  forty-three  cases  of  typhous  fever — ^.  e.,  less  than  one- 
twentieth  of  them. 

"  Discoloration  of  the  walls  of  the  abdomen.,  and  of  the 
sTiin  covering  the  larger  veins.,  was  much  more  frequently  pre- 
sent in  those  dead  from  typhous  than  typhoid  fever. 

"  Emaciation  had  made  greater  progress  in  the  typhoid  than 
in  the  typhous  subjects. 

"  Spots. — The  spots  observed  during  the  progress  of  the  cases 
of  typhous  fever  continued  after  death ;  no  trace  of  the  spots 
visible  during  life  could  be  detected  after  death  from  typhoid 
fever. 

'"'  Head. — After  typhoid  fever,  the  pia  mater  and  arachnoid 
separated  from  the  convolutions  with  abnormal  facility  in  one 
only  of  nine  cases  examined  with  reference  to  the  point.  The 
vessels  of  the  pia  mater  were  abnormally  filled  with  blood  in 
one-third  of  the  cases,  but  intensely  congested  in  one  only  of 
fifteen  cases.  After  typhous  fever,  the  pia  mater  and  arach- 
noid separated  with  abnormal  facility  in  nine  of  eleven  cases 
of  which  notes  on  this  point  were  made.  The  vessels  of  the 
pia  mater  were  congested  in  nearly  half,  and  intensely  congest- 
ed in  one-fifth,  of  the  whole  of  the  cases ;  while  the  cerebral 
substance  itself  was  abnormally  congested  in  half. 


"♦I  may  here  remark,  that  in  one  case  only  of  typhoid  fever,  received 
into  the  London  Fever  Hospital  during  the  last  three  years,  has  Wood  pass- 
ed from  the  bowels.  The  case  referrdd  to  was  that  of  an  old  man  who  had 
hemorrhoids,  which  occasionally  bled  when  he  was  in  health.  During  the 
time  specified,  notes  of  near  two  thousand  cases  have  been  taken. 


132  FEBKILE   F0KM8    OF   DISEASE. 

"  Hemorrhage  into  the  cavity  of  the  arachnoid^  wliich  was 
not  found  in  a  single  case  of  typhoid  fever,  had  occurred  before 
death  in  one-eighth  of  the  cases  of  typhous  fever. 

"  The  amount  of  serosity  found  within  the  cranial  cavity  was 
decidedly  greater  alter  typhous  than  typhoid  fever, 

*''  Pharynx.  —  After  typhoid  fever,  this  organ  was  found 
ulcerated  in  one-third  of  the  cases.  After  typhous  fever,  ul- 
ceration of  the  pharynx  was  not  to  be  detected  in  a  single  case. 

''''Larynx. — Ulceration  of  the  larynx  was  found  in  one  of  fif- 
teen subjects  dead  from  typhoid  fever — in  one  of  twenty-six 
from  typhous  fever. 

'■'■Esophagus. — After  typhoid  fever,  ulcerated  in  one  of  fifteen 
cases  in  w^hich  it  was  examined.  After  typhous  fever,  the  eso- 
phagus was  free  from  ulceration  in  all  the  twenty-four  cases  in 
which  it  was  examined, 

"  The  epithelium  separated  from  the  esophagus  spontaneous- 
ly at  an  earlier  period  after  death  from  the  latter  than  the  for- 
mer disease. 

"  Stomach. — In  none  of  the  fifteen  cases  examined  after 
death  from  typhoid  fever  was  the  mucous  membrane  of  the 
stomach  softened  throughout  its  whole  extent ;  in  no  case  did 
the  softening  of  tiie  cardiac  extremity  approach  perforation. 

"  In  four  of  thirt^'^-seven  cases  of  typhous  fever,  tlie  M'hole 
mucous  membrane  of  the  stomach  was  softened ;  and  in  four 
others,  there  was  such  extreme  softening  of  the  whole  of  the 
coats  of  the  great  cul-de-sac  that  they  were  perforated  by  the 
slightest  violence. 

"  Small  intestines  and  mesenteric  glands. — The  presence  or 
absence  of  lesion  of  these  organs  was  the  ground  on  which  the 
cases  of  typhoid  and  typhous  fever  here  analyzed  were  divided 
from  each  other ;  consequently  they  were  invariably  diseased 
in  the  one  and  normal  in  the  other. 

"  Large  intestines. — After  death  from  typhoid  fever,  the 
mucous  membrane  of  the  large  intestines  was  found  ulcerated 
in  rather  more  than  a  third  of  twenty  cases.  In  no  instance 
after  death  from  typhous  fever. 

"  Peritoneum. — As  peritonitis  was  in  typhoid  fever  secon- 
dary to,  and  dependent  on,  the  eutero-mesenteric  disease,  it  may 
here  be  excluded  from  consideration. 

"  Spleen. — This  organ  was  enlarged  in  all  the  cases  of  ty- 
phoid fever — softened  in  one-third  of  the  cases  only.  Before 
the  age  of  50,  it  was  as  large  after  typhous  as  typhoid  fever ; 
after  that  age,  it  was  decidedly  smaller  in  the  former  than  in 
the  latter  affection.  After  the  age  of  50,  it  was  as  soft  in  ty- 
phous as  in  typhoid  fever ;  before  that  age,  it  was  frequently 
softened. 

"  Gall-hladder. — ^There  was  ulceration  of  the  lining  mem- 
brane of  the  gall-bladder  in  one  of  fourteen  cases  of  typhoid 


FEBKILE    FOEMS  OF  DISEASE.  133 

fever ;  in  none  of  thirty-one  cases  of  typhous  fever.  In  the 
latter  disease,  the  bile  was  much  thicker  and  of  a  darker  green 
color  than  in  the  former.* 

"•  Liver,  pancreas,  kidneys. — These  organs  were  more  flabby 
in  the  cases  of  typhous  than  in  those  of  typhoid  fever. 

"  Urinary -hladder. — This  viscus  was  ulcerated  in  one  of 
the  cases  of  typhoid  fever — in  none  of  the  cases  of  typhous 
fever. 

"  Pericardium. — Thi^  cavity  contained  a  small  amount  of 
yellowish,  transparent  serosity  in  all  the  cases  of  typhoid  fever 
examined.  The  contained  serosity  was  red,  from  transudation 
of  a  solution  of  hsematosin,  in  five  of  thirty-one  cases  of  ty- 
phous fever,  in  which  the  pericardium  was  examined  before 
the  termination  of  the  fever. 

"  Heart. — The  muscular  tissue  of  this  organ  was  much 
more  frequently  and  decidedly  flabby,  and  its  lining  mem- 
brane was  much  more  frequently  and  deeply  stained  of  a  dark- 
red  color,  in  the  cases  of  typhous  fever  than  in  those  of  typhoid 
fever. 

"  Lungs. — Granular  and  non -granular  lobular  consolidation 
were  very  frequent  in  the  subjects  dead  from  typhoid  fever ; 
rare  in  those  dead  from  typhous  fever.  The  reverse  was  the 
fact  with  reference  to  consolidation  from  conjestion  of  the  most 
depending  part  of  the  lung. 

"  Pleura. — Recent  lymph  or  turbid  serosity  was  found  in  six 
of  fifteen  cases  of  typhoid  fever — i. «?.,  between  one-half  and 
one-third,  or  in  the  proportion  of  forty  per  cent.  The  same 
lesions,  but  much  less  in  amount,  were  found  in  two  only  of 
thirty-six  cases  of  typhous  fever — i.  e.,  one-eighteenth,  or  in 
the  propoition  of  5, ft  per  cent. 

"The  particulars  here  briefly  recapitulated,  appear  to  me  to 
prove  indisputably  that  the  symptoms,  course,  duration,  ana- 
tomico-pathological lesions,  and  the  tendency  to  cadaveric 
changes,  are  diflerent  in  typhoid  fever  to  what  they  are  in  ty- 
phous fever. 

"To  account  for  the  differences  in  symptoms  which  exist  in 
continued  fever,  with  or  without  entero-mesenteric  disease,  the 
following  assertions  have  been  put  forward : 

"  1.  That  typhoid  fever  is  merely  typhous  fever  complicated 
with  lesions  of  a  particular  organ  ;  and,  therefore,  it  is  to  be 
expected  that  certain  symptoms  referable  to,  and  dependent  on 
that  lesion,  will  be  present,  and  so  far  modify  the  symptoms  of 
the  disease.     K  the  symptoms  and  signs  referable  to  the  intes- 


"*The  condition  of  the  bile,  as  found  after  death  in  these  two  diseases, 
is  worthy  of  more  careful  investigation.  The  difference  in  appearance  is, 
in  a  large  majority  of  cases,  well  marked.  , 


134  FEBEILE   FORMS   OF  DISEASE. 

tinal  disease  as  a  cause — i.  e.,  the  condition  of  the  tongue,  the 
diarrhea,  increased  resonance,  and  fuUness  of  the  abdomen, 
gurgling  in  the  iliac  fossa,  pain  and  tenderness  in  the  same  re- 
gion from  the  fluctuation  of  the  contents  of  the  bowel — were 
the  only  symptoms  by  which  typhoid  fever  was  separated  from 
typhous  fever,  although  the  idea  might  cross  the  mind  that 
they  were  two  diseases,  no  sufficient  ground  for  their  separa- 
tion would  be  present,  unless  the  specific  cause  of  the  one  was 
proved  to  be  diflerent  from  that  of  fhe  other.  Bat,  putting 
aside  the  symptoms  strictly  referable  to  the  abdominal  lesion, 
the  general  symptoms  of  the  two  diseases,  in  the  cases  here 
analyzed,  differed  widely ;  such  differences  having  no  apparent 
connection  with  the  local  afiection,  but  being  probably,  like  it, 
dependent  on  some  common  cause  acting  on  the  whole  system 
simultaneously. 

"  Thus  the  remarkable  difference  in  the  kind,  not  simply 
the  amount,  of  the  rash  in  the  two  diseases  ;  and  the  tendency 
to  local  inflammations,  to  erysipelas,  and  to  ulceration,  observ- 
ed in  the  cases  of  typhoid  lever  here  analyzed,  can  not,  with 
an}'^  show  of  reason,  he  considered  to  have  been  dependent  on 
the  disease  of  Peyer's  patches — i.  6.,  in  the  same  way  as  the 
abdominal  signs  undoubtedly  were ;  and  it  is  to  be  carefully 
borne  in  mind  that  the  external,  the  hygienic  conditions  of 
either  group  of  cases  were  precisely  the  same  in  all  respects. 
They  occupied  the  same  wards,  jjartook  of  the  same  diet,  slept 
on  the  same  beds,  under  the  same  amount  of  clothing,  and  had 
the  same  physicians  to  attend  them,  and  the  same  nm*ses  to 
wait  on  them. 

"Moreover,  of  the  symptoms  common  to  the  two,  the  head- 
ache continued  longer,  and  the  delirium  and  somnolence  came 
on,  as  we  have  seen,  much  later,  in  typhoid  than  in  typhous 
fever ;  and  the  delirium,  too,  possessed  a  more  active  charac- 
ter. These  differences,  also,  can  not  be  explained  by  the  pres- 
ence of  intestinal  disease  in  the  former,  and  its  absence  in  the 
latter  affection. 

"  The  short  comparative  duration  of  the  cases  of  typhous 
fever  here  considered,  is  another  remarkable  point  of  differ- 
ence, totally  inexplicable  by  the  hypothesis  that  typhoid  fever 
is  typhous  fever  with  intestinal  ulceration.  Had  the  cases 
eventually  recovered,  it  might  have  been  said  that  the  intes- 
tinal lesion  prolonged  the  disease  in  the  cases  of  typhoid  fever ; 
but  that  all  the  fatal  cases  of  fever,  with  a  local  lesion  of  so  se- 
vere a  nature  as  that  recorded  to  have  been  present  in  the  cases 
of  typhoid  fever,  should  have  had  a  much  longer  course  than 
all  those  other  fatal  cases  of  fever  in  which  no  organic  change 
of  structure  could  be  detected  after  death,  appears  to  me  inex- 
plicable, on  the  supposition  that  the  former  is  simply  the  latter 
disease,  with  this  serious  lesion  superadded.     Let  me  repeat, 


FEBEILE   FOEMS   OF   DISEASE.  135 

by  this  hypothesis  we  are  asked  to  imagine  that  death  is  re- 
tarded in  fever  by  extensive  ulceration  of  the  small  intestines, 
and  enlargement,  softening,  and  even  suppuration  of  the  mesen- 
teric glands.  Surely,  it  behooves  the  supporters  of  such  a 
statement  to  bring  forward  cogent  proofs  of  the  identity  of  the 
specific  cause  of  the  two  affections  ere  they  ask  us  to  admit  its 
truth. 

"  The  same  mode  of  reasoning  appears  to  me  equally  con- 
clusive, when  we  consider  the  comparatively  early  period  of 
the  disease  at  which  the  patients  suffering  from  fever  lost  the 
ability  to  make  muscular  exertion.  For,  to  suppose  that  the 
presence  of  abdominal  complication  in  fever  invariably  pre- 
vented the  extremely  early  supervention  of  debility  is,  a  priori^ 
still  more  absurd  than  to  suppose  such  lesions  to  have  retarded 
death.  How,  again,  are  we  to  explain,  if  we  regard  typhoid 
as  typhous  with  abdominal  complication,  the  differences  ob- 
served in  the  ages  of  the  patients  ;  in  their  general  manner ; 
the  muddy  hue  of  tlie  skin  and  uniform  flush  of  the  face,  the 
injected  conjunctivae  and  contracted  pupils,  in  typhous  fever ; 
and  the  comparatively  clear  complexion,  the  pink  flush  limited 
to  the  cheeks,  the  pale  conjunctivae,  and  the  large  pupils,  in 
typhoid  fever? 

'•In  what  way,  also,  are  we  to  account  for  the  differences 
observed  in  the  physical  breath-signs,  on  the  supposition 
that  the  one  is  merely  the  other  with  abdominal  compli- 
cation ? 

"  Death  itself,  moreover,  adds  new  proof  to  the  non-identity 
of  the  general  affection  in  the  two  diseases.  The  comparative- 
ly rapid  loss  of  muscular  rigidity,  the  discoloration  of  the  sur- 
face, the  more  flabby  condition  of  the  heart,  liver,  and  kid- 
neys, the  extreme  softening  of  the  stomach,  and  the  early 
separation  of  the  epithelium,  after  typhous  fever,  are  all 
cadaveric  changes,  by  which  death  makes  us  cognizant  of  a 
condition  of  the  system  at  large,  which  condition  must  have 
existed  anterior  to  the  cessation  of  life  from  that  disease ;  and 
which  condition  could  not  have  been  present  in  the  cases  of  ty- 
phoid fever,  or  death  would  have  made  it  manifest. 

"  I  need  not  here  more  than  advert  to  the  differences  ob- 
served in  the  lesions  which  death  simply  enabled  us  to  lay 
bare.  The  almost  constantly-congested  brain  and  membranes 
in  typhous  fever;  the  frequent  presence  of  the  signs  of  pre- 
existing serous  inflammation  in  typhoid  fever;  the  differ- 
ence in  the  nature  of  pulmonary  lesions  in  the  two — are  inex- 
plicable on  the  supposition  that  the  one  disease  is  the  same 
as  the  other,  excepting  so  far  as  concerns  the  abdominal  af- 
fection. 

"Thus  tried   by  facts  —  i.  e.,  by  recorded  symptoms  and 


136  FEBKILE   FORMS    OF   DI3Ex\.SE. 

lesions — the  assertion  that  typhoid  fever  is    merely  typhous 
with  abdominal  complication,  is  completely  retiited. 

"  2d.  But  another  mode  of  explaining  the  diiferences  which 
exist  between  the  two  diseases  have  been  given — i.  e.,  that  the 
differences  observed  depend  on  variations  in  tlie  epidemic  con- 
stitution. These  cases  afiord  a  complete  answer  to  this  asser- 
tion. For  a  majority  of  the  cases  here  analyzed  of  both  dis- 
eases were  observed  during  the  same  epidemic  constitution.  K 
the  reader  will  refer  to  vol.  xix,  p.  668  Amer.  Jour.  Med.  Sci., 
he  will  find  that  nineteen  of  the  cases  of  typhous  fever  I  have 
used  were  collected  between  May  and  November,  1848 ;  and  that 
thirteen  of  the  cases  of  typhoid  fever  were  collected  during  the 
same  months  of  the  same  year.  For  such  as  prefer  broad,  general 
assertions  to  the  details  of  a  particular  but  more  limited  facts, 
I  may  remark,  that  during  the  three  years'  attentive  watching 
of  nearly  all  the  cases  admitted  to  the  London  Fever  Hospital, 
in  which  time  there  have  been  epidemics  of  relapsing  fever, 
typhous  fever,  and  cholera — and,  consequently,  according  to 
those  whose  opinions  I  am  here  examining,  as  many  changes 
in  epidemic  constitution — I  have  seen  no  alteration  in  the  gen- 
eral or  particular  symptoms  of  either  typhous  or  typhoid  fe- 
vers, or  the  lesions  observed  after  death  from  either — /.  «.,from 
^S'ovember,  1846,  to  November,  1849.  The  cases  of  typhoid 
fever — which  disease  is  rarely  absent  for  a  fortnight  from  the 
wards  of  the  hospital — preserved  their  symptoms  unchanged, 
and  presented  the  same  lesions,  wha{:ever  the  epidemic  consti- 
tution that  prevailed ;  the  same  is  true  of  typhous  fever. .  Cases 
of  the  latter  disease  are  also  rarely  absent  from  the  wards  of 
the  same  institution.  It  is  there  common  to  see  patients  occu- 
pying beds  side  by  side,  and  presenting  respectively  the  well- 
marked  characters  of  either  disease. 

"But  to  return  to  the  particular  cases  before  analyzed.  Al- 
lowing to  epidemic  constitution  all  the  power  of  modifying  dis- 
ease claimed  for  it  by  certain  writers,  it  must  be  granted  that 
whatever  influence  this  epidemic  constitution  exercised  over  the 
group  of  cases  without  intestinal  lesion,  it  ought  to  have  exercised 
over  the  group  of  cases  with  intestinal  lesion,  because  the  cases 
of  the  two  groups  were  scattered  indiscriminately  over  the  space 
of  two  years  only.  If,  I  repeat,  the  two  afiections  were  really 
the  same  disease,  then  the  same  epidemic  constitution  ought  to 
have  impressed  on  both  the  same  general  features,  implanted 
in  both  the  same  local  lesions,  and  given  to  both  the  same  ten- 
dency to  cadaveric  changes,  and  this  allowing  for  all  the  modi- 
iying  influence  which  the  accidental  presence  of  the  abdominal 
lesion  in  the  one  and  its  absence  from  the  other  group  might 
have  occasioned.  The  analysis  of  every  symptom,  and  every 
lesion,  shows  that  the  two  aiiections  were  not  thus  assimilated 
by  the  prevalence  of  any  particular  epidemic  constitution.    But 


FEBRILE    FORMS    OF   DISEASE.  137 

if  this  epidemic  constitution,  by  any  stretch  of  the  imagina- 
tion, could  be  supposed  to  change  from  week  to  week,  to  cause 
the  case  attacked  to-day  to  have  typhous  fever,  the  individual 
who  takes  the  disease  to-morrow  to  have  typhoid  fever,  still, 
it  could  not  account  for  the  fact — as  well  established  as  any 
fact  in  medicine — that  typhoid  fever  rarely,  if  ever,  aflects  per- 
sons more  than  fifty  years  of  age ;  while  age  exerts  little  in- 
fluence in  determining  the  occurrence  of  typhous  fever. 

"  Thus,  then,  the  assertion  that  typhoid  fever  is  merely  ty- 
phous fever  modified  by  the  prevailing  epidemic  constitution, 
is  as  irreconcilable  with  facts,  as  that  the  former  disease  is  sim- 
ply the  latter  with  abdominal  complication. 

"To  conclude: — In  a  former  paper,  I  proposed  to  examine 
whether  typhoid  fever  and  typhous  fever  differed  from  each 
other  in  the  same  way  as  small-pox  and  scarlet  fever  difiered 
ti'om  each  other ;  and  for  the  purpose  of  comparison,  I  laid  down 
certain  grounds,  as  those  on  which  we  founded  our  belief  in 
the  non-identity  of  the  two  last  named  diseases.  Those  grounds 
were : 

"  1.  In  the  vast  majority  of  cases,  the  general  symptoms  dif- 
fer— i.  e.,  of  small-pox  and  scarlet  fever. 

"  [This  holds  equally  true  with  respect  to  the  general  symp- 
toms of  typhoid  and  typhous  fevers. 

"2.  The  eruptions,  the  diagnostic  characters,  if  -present^  are 
never  identical — i.  e.,  in  small-pox  and  scarlet  fever. 

"  [The  particulars  detailed  in  the  foregoing  papers  prove  that 
this  is  true  ox  -  he  eruptions  of  typhoid  and  typhous  fevers,  as 
of  those  of  small-pox  and  scarlet  fever.] 

"  3.  The  anatomical  character  of  small-pox  is  never  seen  in 
scarlet  fever. 

"  [Just  in  the  same  way,  the  anatomical  character  of  typhoid 
fever — i.  «.,  lesion  of  Peyer's  patches  and  the  mesenteric  glands 
— is  never  seen  in  typhoid  fever.] 

"4.  Both — i.  e.,  small-pox  and  scarlet  fever — being  conta- 
gious diseases,  the  one  by  no  combination  of  i'ndividual  pecu- 
liarities, atmospheric  variations,  epidemic  constitutions,  or  hy- 
gienic conditions,  can  give  rise  to  the  other  disease. 

"'[In  this  paper,  I  have  not  attempted  to  determine  how  far 
this  holds  true  with  respect  to  the  diseases  here  treated ;  but  I 
have  considered  it  in  a  paper  read  before  the  Medico-Chirurgi- 
cal  Society  of  London,  December,  1849),  [Amer.  Jour.  Med. 
Sci.,  vol.  XX.,  p.  384],  the  contents  of  which  I  may  anticipate 
so  far  as  to  state  that,  to  my  mind,  the  origin  of  the  two  dis- 
eases from  distinct  specific  causes  is  as  clearly  proved  as  that 
scarlet  fever  and  small-pox  arise  from  distinct  specific  causes.] 

"  5.  The  epidemic  constitution  favorable  to  the  origin,  spread, 
or  peculiarity  in  form  or  severity  of  either — i.  e.,  small-pox  and 


138  FEBRILB  FORMS  OF  DISEASE. 

scarlet  fever  —  has  no  influeDce  over  the  other,  excepting  that 
which  it  exerts  over  disease  in  general. 

''  [The  facts  detailed  in  this  paper  prove  that  this  holds  as 
true  of  typhoid  and  typhous  fevers  as  of  small-pox  and  scar- 
let fever. 

"  If,  then,  the  above  are  the  grounds — and,  after  mature  de- 
liberation, I  am  able  to  assign  no  others — for  the  separation 
of  small-pox  from  scarlet  lever,  I  think  it  is  indisputably 
proved  that  typhoid  fever  and  typhous  fever  are  equally  dis- 
tinct diseases ;  not  mere  varieties  of  each  other,  but  speci- 
fically distinct —  specific  distinction  being  shown  in  typhoid 
and  typhous  fevers,  as  in  small-pox  and  scarlet  fever,  by 
the  difierence  of  their  symptoms,  course,  duration,  lesion,  and 
cause. 

"  Before  closing  this  paper,  I  ought  to  observe  that,  with 
respect  to  some  secondary  points — e.g.^  the  chronological  rela- 
tion between  the  laryngeal  and  pharyngeal  aflections — it  may 
be  considered  that  I  have  drawn  general  conclusions  from  a 
too  limited  number  of  facts.  But  a  few  facts,  impartially  ob- 
served, minutely  recorded,  and  carefully  analyzed,  are,  I  be- 
lieve, more  likely  to  give  correct  results  than  a  multitude  of 
general  observations ;  and  moreover,  I  believe  most  men 
woul  1  be  astonished,  if  they  had  in  numbers  all  the  cases  of 
any  given  disease  they  had  ever  seen,  yet  concerning  which 
they  have  generalized.  The  method  I  have  adopted,  however 
prolix  it  may  be,  however  difiicult  to  conform  to,  however 
tedious  the  details  into  which  it  leads,  has  this  advantage, 
that,  if  the  observer  be  honest  and  capable  of  noting  what  is 
before  him,  thinking  men  may  judge  of  the  value  of  his  facts, 
the  force  of  his  reasoning,  and  the  correctness  of  his  conclusion  ; 
whereas,  general  observations,  while  they  are  incapable  of  prov- 
ing anything,  are  exposed  to  all  the  fallacies  of  definite  state- 
ments, because  the  one,  like  the  other,  rests  ultimately  on  the 
accuracy  of  the  facts  observed.  If  the  observations,  on  which 
any  reasoning  is  founded,  be  erroneous,  no  cloaking  of  those 
observations,  in  general  terms,  can  render  the  conclusions  cor- 
rect. It  has  been  objected  to  definite  numerical  statements, 
that  they  mislead  the  reader  by  an  appearanee  of  accuracy,  in 
cases  where  there  has  been  great  inaccuracy  in  observation. 
This  objection  appears  tome  to  lie  against  the  condition  of  the 
reader's  mind,  and  not  against  the  method.  For  if  the  reader 
fails  to  examine,  1st,  the  trustworthiness  of  the  author,  and, 
2dly,  the  legitimacy  of  his  conclusions,  the  fault  is,  obviously, 
mentally  his  own.  and  in  no  way  to  be  ascribed  to  the  method. 
Because  chemists  have,  by  the  imperfection  of  their  analysis, 
arrived  at  incorrect  conclusions  as  to  the  ultimate  constitution 
of  various  organic  bodies,  we  surely  would  not  have  them 
henceforth  confine  themselves  to  the  general  impressions  pro 


FEBKILE    FORMS   OF  DISEASE.  139 

duced  on  their  minds  by  a  series  of  experiments  or  observa- 
tions. The  more  complicated  the  problem  to  be  solved,  the 
more  careful  ought  we  to  be  that  every  step  in  its  solution  is 
made  correctly.  How  complex  questions,  such  as  arise  in 
medicine,  are  to  be  determined  mentally — i.  e.,  without  the  aid 
of  figures  —  by  ordinary  men,  I  am  a  loss  to  conceive.  Yet 
physicians  think  to  solve,  by  mental  reveries,  problems  in  com- 
parison with  which  the  most  difficult  that  the  most  renowned 
mental  calculators  ever  answered,  were  child's  play;  and  not 
only  do  they  think  to  solve  these  problems,  but  to  carry  in  their 
minds  for  years  the  complicated  materials  by  which  they  are 
to  be  solved. 

"Who  can  tell  what  general  statements  are  worth,  without 
knowing  on  what  evidence  they  rest  ?  One  man's  many,  is 
another's  few.  Last  month  (October),  I  saw  thirty  cases  of 
fever.  To  me,  these  were  few  ;  to  men  with  smaller  opportu- 
nities of  observing  that  disease,  they  would  have  been  many. 
One  man's  frequent,  is  another's  seldom." 

Speaking  upon  the  use  of  stimutants  in  the  treatment  of  con- 
tinued fever.  Dr.  Tweedie,  Physician  to  the  London  Fever 
Hospital,  etc.,  in  his  recent  Lumleian  lectures  before  the  Royal 
College  of  Physicians,  says : 

"It  is  always  necessary  to  watch  the  effects  of  the  first  few 
doses  of  wine,  and  if  the  pulse  abates  in  frequency,  becomes 
soft  and  fuller,  the  tongue  moist,  and  the  heat  of  the  skin  not 
increased ;  and,  when  there  has  been  delirium,  if  the  patient 
becomes  more  calm,  and  has  intervals  of  sleep,  we  may  feel 
sure  that  the  wine  is  doing  good.  On  the  other  hand,  if  the 
pulse  increases  in  frequency  and  strength,  the  skin  becomes 
hotter,  and  the  patient  restless,  flushed,  and  excited,  with  throb- 
bing of  the  temporal  and  carotid  arteries,  we  may  consider 
either  that  wine  is  not  suited  to  the  case,  or  has  been  given 
too  early,  and  should,  therefore,  be  withdrawn.  But,  as  a  gen- 
eral rule,  it  is  perhaps  better  to  give  wine  a  little  too  early  than 
a  little  too  late,  since  if  it  appears  to  disagree,  it  is  easy  to  sus- 
pend its  use ;  but  it  may  be  very  difficult  to  restore  the  vital 
powers  if  they  have  been  allowed  to  remain  too  long  unsup- 
ported. 

"  Nor  should  the  wine  or  brandy  be  discontinued  until  conval- 
escence is  fairly  established ;  but  as  the  symptoms  for  which 
the  stimulants  have  been  prescribed  disappear,  the  quantity 
should  be  gradually  abridged  by  giving  smaller  portions  and 
at  more  distant  intervals. 

"  In  regard  to  the  amount  of  wine  and  alcoholic  stimulants 
that  may  be  administered  in  typhus,  no  precise  rules  can  be 
laid  down,  as  the  ever-varying  circumstances  presented  by  in- 
dividual cases  can  alone  determine  this.  It  is  prudent  to  begin 
with  half  an  ounce  or  an  ounce,  and  to  repeat  this  amount  at 


140  FEBRILE  F0KM8   OF  DISEASE. 

longer  or  shorter  iutervals,  according  to  the  effect  produced. 
From  six  to  twelve  ounces  may  be  considered  to  be  an  average 
daily  allowance,  but  sometimes  it  is  necessary  to  give  two  or 
three  pints,  or  even  more,  in  twenty-four  hours,  and  it  is  sur- 
prising to  observe,  without  the  slightest  intoxicating  effect,  even 
when  the  patient  has  been  previousl}"^  unaccustomed  to  stimu- 
lants. Indeed,  in  low  fevers,  the  exhausted  state  of  the  nerv- 
ous system  appears  to  be  autidote  to  the  effects  of  stimulants — 
in  short,  to  create  a  tolerance  of  wine  and  diffusible  stimulants. 

''The  wine  should  always  be  conjoined  with  nourishment,  in 
order  to  assist  its  due  assimilation,  though  in  many  cases  the 
digestive  powers  are  so  feeble  that  they  are  unable  to  elaborate 
even  the  lightest  articles  of  food,  and,  therefore,  the  wine  or 
brandy  may  be  given  simply  diluted  with  water. 

"I  have  just  alluded  to  the  daily  quantity  of  wine  that  it 
may  be  necessary  to  prescribe  in  typhus,  and  stated  that  no 
precise  rules  can  be  laid  down,  as  the  circumstances  of  each 
case  must  determine  it.  You  are  doubtless  aware  that  there 
is  a  great  tendency  in  the  present  day  to  revive  the  Browno- 
nian  system,  which  flourished  for  a  time  in  the  latter  part  of 
the  last  century,  in  all  acute  diseases,  including  fevers,  withoat 
regard  to  individual  peculiarities.  The  doctrine  inculcated  by 
some  teachers  with  respect  to  inflammation  is,  that  this  pro- 
cess being  a  deranged  nutrition,  involving  supply  and  waste, 
and  the  w^aste  being  considerable  while  the  inflammatory  process 
lasts,  there  must  be  a  compensating  supply  ;  that  as  the  sup- 
plies for  the  formation  of  the  abnormal  products  of  pus  and 
lymph  must  be  drawn  from  the  blood,  or  from  the  tissues,  or 
from  both,  the  vital  powers  become  exhausted,  in  proporation 
to  the  organic  disintegration  that  takes  place.  Hence  it  is 
concluded,  that  the  more  the  inflammatory  process  draws  upon 
the  blood,  the  greater  will  be  the  exhaustion  of  vital  force,  and 
the  consequent  effect  upon  the  whole  frame. 

"  Upon  this  physiological  theory  of  the  phenomena  of  in- 
flammation, is  based  the  overthrow  of  established  therapeu^tic 
principles,  on  which  the  treatment  has  been  for  ages  conducted. 
But  surely  even  the  abettors  of  this  theoretical  view  must  ad- 
mit that  the  object  of  treatment  is  to  anticipate  or  prevent 
those  so-called  destructive  processes :  in  other  words,  to  pro- 
mote resolution  by  all  available  means.  Is  this  to  be  accom- 
plished by  extravagant  doses  of  wine  and  brandy,  regardless 
of  the  every- varying  condition  of  the  sufferer  or  period  of  the 
disease  ? 

"  Similar  reasoning  is  adduced  in  regard  to  the  phenomena 
of  fevers,  whatever  be  their  type  or  special  circumstances.  It 
is  against  the  indiscriminate  employment  of  stimulants  in  fever 
that  we  protest,  being  convinced  that  their  proper  administra- 


FEBKILE  FORMS   OF   DISEASE.  141 

tion  requires  as  much  consideration  as  is  generally  bestowed 
on  other  measures  employed  as  curative  agents. 

"  The  enormous  quantities  of  wine  and  brandy  recommended 
in  even  the  early  stage  of  fevers,  whatever  be  the  form,  the 
individual  circumstances,  or  whether  there  be  local  afl'ections 
present,  have  often  surprised  me,  and  inclined  me  to  doubt  the 
accuracy  of  the  statements.  I  have  certainly  seen  intercurrent 
inflammations  materially  aggravated  by  the  injudicious  stimu- 
lation adopted,  and  on  more  than  one  occasion  all  the  ordinary 
characters  of  acute  delirium  tremens  supervene  when  the  un- 
limited administration  of  brandy  had  been  left  to  the  discretion 
of  a  nurse,  who  fancied  that  she  was  only  obeying  instructions 
when  she  poured  down  dose  after  dose  of  pure  brandy.  There 
is  surely  no  practical  philosophy  in  such  indiscriminate  abuse 
of  a  really  valuable  remedy  when  given  on  rational  principles  ; 
and  I  deem  it  the  duty  of  every  physician  who  is  convinced  of 
the  dangerous  tendency  of  the  Brownonian  doctrine  applied 
indiscriniinately  in  the  treatment  of  diseases,  acute  as  well  as 
chronic,  to  express  his  opinion  boldly  and  decidedly,  that  the 
young  and  inexperienced  practitioner  may  be  warned  of  the 
dangerous  consequences  of  this  recently  revived  doctrine.  *  *  * 

"  Let  me  also  allude  to  the  importance  of  giving  the  wine 
at  stated  intervals,  and  only  when  the  excitement  is  moderate. 
It  is  especially  necessary  to  give  it  during  the  night,  when 
there  is  often  great  exhaustion.  A  dose  of  wine  judiciously 
given  at  this  diurnal  period  is  often  followed  by  calm,  refreshing 
sleep  ;  and  hence  the  incalculable  advantage  of  an  interested, 
experienced  nurse,  on  whom  so  much  responsibility — indeec 
the  life  of  the  patient — often  rests." 

On  the  question  of  change  of  type  in  fever.  Dr.  Tweedie  says : 
"If  we  examine  closely  this  theory  as  applicable  to  the  acute  dis- 
eases of  the  last  thirty  years — and  this  can  only  be  undertaken 
by  those  who  have  witnessed  and  studied  their  type  during  the 
period  referred  to — and  weigh  dispassionately  the  evidence 
adduced,  more  especially  by  nature  herself,  I  apprehend  that 
the  true  explanation  of  the  difference  of  treatment  will  be  found 
to  consist  in  the  more  cautious  or  restricted  notions  now  enter- 
tained as  to  the  necessity  for  the  heroic  remedies  formerly  so 
freely,  and  I  may  say  indiscriminately,  adopted.  Even  those 
who  are  in  favor  of  this  doctrine,  can  not  assert  that  the  patho- 
logical phenomena  of  acute  diseases  have  undergone  a  change, 
for  the  symptoms,  general  and  local,  and  all  the  essential  mor- 
bid processes  of  the  entire  class  of  pyrexial  diseases,  have  not 
undergone  the  slightest  alteration ;  and  if  the  evidence  as  to 
the  depressed  or  asthenic  condition  of  the  vital  powers  be 
scrutinized,  I  have  a  strong  impression  that  the  conclusions 
adopted,  more  especially  in  reference  to  fevers  as  a  class,  are 
not  warranted  by  facts.     And  how  important  is  it  to  form  a 


142  FEBEILE   FORMS   OF   DISEASE. 

correct  judgment  of  this  doctrine,  since  it  determines  the  line 
of  treatment  to  be  pursued,  and  may  even  involve  the  safety 
of  many  valuable  lives  ! 

"  The  subject  has  not  escaped  my  attention,  and  I  have  come 
to  the  conclusion,  that  though  certain  cyclical  differences  in 
acute  diseases,  of  longer  or  shorter  duration,  may  have  been 
occasionally  detected,  the  notion  of  change  of  type,  as  regards 
the  various  forms  of  fever,  has  been  greatly  exaggerated. 

'•  Let  me  state  the  grounds  upon  which  I  have  come  to  this 
conclusion,  which  I  admit  is  at  variance  with  the  ideas  of  many 
physicians  whose  knowledge  and  judgment  entitle  them  to 
great  consideration. 

"  We  find  that  Sydenham,  who  is  considered  to  be  the  author 
of  this  change-of-type  theory,  cautioned  the  medical  men  of 
his  day  against  too  hastily  determining  the  treatment  of  a  new 
epidemic — until,  in  short,  the  practitioner  and  the  disease  were 
better  acquainted — on  the  reasonable  ground,  that  epidemics 
assumed  at  one  time  a  more  acute  or  phlogistic,  at  another  a 
less  acute,  or  asthenic  character ;  but  we  do  not  find  that  he 
had  observed  a  change  in  one  direction  only,  and  for  so  length- 
ened a  period  as  considerably  more  than  a  quarter  of  a  century. 
If  the  records  of  epidemics  of  other  varieties  of  fever  be  ex- 
amined— the  eruptive,  for  example — it  will  be  evident  that, 
during  the  same  period  (in  small-pox,  measles,  and  scarlet 
fever),  every  variety  or  modification  of  type  has  been  observed, 
the  type  being  sometimes  acute,  sometimes  more  or  less  asthe- 
nic, and  requiring,  consequently,  variation  in  treatment. 

"  I  apprehend  that  the  true  explanation  will  be  found  in  the 
fact  that,  until  very  recently,  little  or  no  attention  has  been 
paid  to  the  ever-varying  differences  in  form  which  fever  as- 
sumes— at  one  time  typhas,  at  another  enteric  or  typhoid,  or 
it  maybe  relapsing  fever, constituting  the  features  of  tiie  prev- 
alent fever,  though  it  should  be  kept  in  view  that,  whatever  be 
the  character  or  type  of  an  epidemic,  individual  differences 
arise,  according  to  the  peculiar  circumstances  in  which  a  sin- 
gle individual,  or  a  number  of  persons,  or  a  community,  may 
be  accidentally  placed.  The  question  of  the  identity  or  non- 
identity  of  the  several  forms  of  continued  fevers  thus  becomes 
of  the  greatest  importance  in  relation  to  the  change-of-type 
theory.  For  example,  the  great  argument  adduced  by  those 
who  support  the  doctrine  is,  the  decided  results  in  the  Edin- 
burgh epidemic  of  181T-20 — and  which  I  had  the  opportunity 
of  witnessing — of  the  large  indiscriminate  bleedings  in  dimin- 
ishing the  mortality.  This  argument,  however,  loses  much  of 
its  intended  effect  when  it  is  considered  that  by  much  the  larger 
number  of  cases  consisted  of  relapsing  fever — a  form  the  mor- 
tality from  which  has  already  been  shown  to  be  exceedingly 
small  under  any  kind  of  treatment ;  and  that  the  death-rate 


FEBRILE   FORMS   OF  DISEASE.  143 

has  been  even  less  when  no  blood  was  abstracted  at  all.  As 
in  other  epidemics,  the  mildness  or  severity  of  the  fever  has 
varied  at  different  times.  We  are  told,  somewhat  exnltingly, 
that  under  the  nnnecessarily  profuse  phlebotomy  practiced  in 
1817-20,  the  mortality  did  not  exceed  1  in  22  at  any  period  of 
the  disease,  and  was  reduced  so  low  as  1  in  30  as  the  epidemic 
spread ;  but  in  the  argument  it  has  been  overlooked  that  the 
mortality  of  this  fever  is  liable  to  much  variation.  For  exam- 
ple, in  the  epidemic  of  1843,  the  history  of  which  has  been 
given-  by  Dr.  Cormack,  the  deatlis  were  1  in  16 ;  of  the  cases 
recorded  by  Dr.  Wardell  (1843-4),  it  was  1  to  20  ;  and  of  203 
cases  treated  in  the  Edinburgh  Infirmary  in  1848-9,  there  were 
only  8  deaths  ;  and  if  we  extend  our  inquiries  to  other  places, 
we  find  tliat  of  7804  cases  of  relapsing  fever  admitted  into  the 
Glasgow  Infirmary,  between  the  years  1843  and  1853,  the  deaths 
were  405,  or  about  5  per  cent.;  and  in  the  London  Fever  Hos- 
pital, of  441  cases  admitted  during  ten  years  (1848  to  1857), 
11  died,  or  in  the  ratio  of  about  1  to  40. 

"  This  variation  in  the  mortality  could  not  be  ascribed  to  the 
remedies  employed  ;  for  Dr.  Cormack  states,  that  having  been, 
urged  by  medical  friends  to  test  the  effects  of  blood-letting,  he 
instituted  trials  of  this  remedy ,'but  candidly  admitted  that, 
though  the  symptoms  were  sometimes  evidently  relieved,  the 
beneficial  changes  were  often  not  effects  but  sequences  of  the 
bleeding,  as  was  satisfactorily  proved  by  the  very  same  changes 
frequently  occurring  as  suddenly  and  unequivocally  in  patients 
in  the  same  wards,  and  affected  in  the  same  way,  who  were 
subjected  to  no  treatment  whatever.  And  in  regard  to  the 
treatment  instituted  at  the  London  Fever  Hospital,  when  the 
mortality  of  relapsing  fever  did  not  exceed  one  in  forty,  with 
scarcely  an  exception,  no  blood  was  pbstracted  at  any  period 
of  the  disease. 

"  It  is  clear,  therefore,  that  the  change-of-type  theory  can  not 
rest  on  comparison  of  the  treatment  by  indiscriminate  phle- 
botomy formerly  practiced,  when  all  acute  diseases,  including 
fevers,  were  supposed  to  be  under  the  dominion  of  the  lancet. 

''  But  though  the  grounds  on  which  the  question  has  been 
argued  are,  in  my  opinion,  erroneous,  one  good  result  has  fol- 
lowed in  the  death-blow  which  the  practice  of  indiscriminate 
phlebotomy,  formerly  adopted  in  all  acute  maladies,  has  re- 
ceived ;  for,  too  often,  little  or  no  regard  was  paid  to  individual 
peculiarities,  or  even  to  the  stage  of  the  disease  for  which  the 
bleeding  was  employed.  The  inquiry  was  simply  as  to  the 
existence  of  fever  or  of  inflammation;  and,  the  question  once 
settled,  the  lancet  was  unsheathed,  and  much  blood  unneces- 
sarily shed,  and  from  the  effects  of  which  the  patient  did  not 
recover,  perhaps,  for  months.  But,  on  the  other  hand,  there 
is  great  hazard  of  many  important  diseases  being  allowed  to 


144  FEBRILE  FORMS   OF  DISEASE. 

gain  the  ascendancy  from  the  indecision  that  has  resulted  from 
the  complete  alteration  of  therapeutic  principles  which  the  dis- 
cussion of  this  question  has  brought  about.      *         *         * 

"  It  is  consoling  to  observe  that,  in  the  present  day,  there  is 
a  more  just  appreciation  of  the  powers  of  curative  agents,  as 
well  as  of  the  principles  on  which  they  should  be  applied,  not 
only  in  acute  but  in  chronic  diseases.  This  is  the  consequence 
of  studying  the  effects  of  disease  on  individual  structures,  and  of 
the  efficacy  or  inefficacy  of  remedies  to  subdue  the  changes 
that  take  place  when  certain  morbid  actions  have  become 
established.  We  are  now,  or  ought  to  be,  satisfied,  that  the 
most  scientific,  as  well  as  the  most  successful  course,  in  many 
acute  diseases,  after  a  certain  period,  is,  not  to  interfere  too 
much,  if  at  all,  with  the  operations  of  nature  in  her  efforts  to 
repair  the  injury  the  parts  or  organs  have  sustained  by  disease." 


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WB920 

N565e 

1861 
Newton,  Robert  S 

An  eclectic  treatise  on  the  practice 
of  medicine 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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